Произход и развитие
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..
Класификация
Medicalinsurance,likeothertypesofinsurance,alsocollectsmedicalinsurancepremiumsfrompersonsthreatenedbydiseasesinadvancebymeansofcontractstoestablishamedicalinsurancefund;Ifyougetsickandgotoamedicalinstitutionformedicaltreatmentandincurmedicalexpenses,themedicalinsuranceinstitutionwillgiveyouacertainamountoffinancialcompensation.Therefore,medicalinsurancealsohastwomajorfunctionsofinsurance:risktransferandcompensationtransfer.Thatis,theeconomiclosscausedbythediseaseriskontheindividualisallocatedtoallmembersthreatenedbythesamerisk,andthecentralizedmedicalinsurancefundisusedtocompensatetheeconomiclosscausedbythedisease.
Търговска медицинска застраховка
Itcanbedividedintoreimbursementmedicalinsuranceandcompensationmedicalinsurance.
Reimbursementtypemedicalinsurancemeansthatthemedicalexpensesspentbypatientsinthehospitalarereimbursedbyinsurancecompanies,generallydividedintooutpatientmedicalinsuranceandhospitalizationmedicalinsurance.
IndemnityMedicalinsurancemeansthatthepatientisclearlydiagnosedbythehospitalassufferingfromacertaindiseaselistedinthecontract,andtheinsurancecompanypaysthepatientfortreatmentaccordingtotheamountagreedinthecontractAndcare.Generally,itisdividedintosingleitemsicknessinsuranceandcriticalillnessinsurance.
Theabovetwotypesofmedicalinsurancehavethesamepointsbutdifferentpoints.Thesamepointisthatyoucangetinsurancebenefitsonlywhenyougetsick.Themaindifferenceis:generalmedicalinsurancebelongstoalltypes,thatis,allkindsofdiseasescanbecovered.Pay.Specialmedicalinsurancebelongstothespecialcategory,thatis,onlyacertaindiseaseoroperationspecifiedintheinsurancecontractcanreceiveinsurancebenefits.Medicalinsurancelaunchedbyinsurancecompaniesisoftencombinedwithpartsoftheabovetwotypesofinsurance.
Вид плащане на субсидия
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.
Роля
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.
Условия за възстановяване
AccordingtoArticle28ofthe"SocialInsuranceLaw",itmeetsthebasicmedicalinsurancedrugcatalog,diagnosisandtreatmentitems,medicalservicefacilitystandards,andemergencyandrescueMedicalexpensesshallbepaidfromthebasicmedicalinsurancefundinaccordancewithnationalregulations.
Accordingtothebasicrequirementsforthepaymentofbasicmedicalinsurancebenefitsinourcountry,theinsuredpersonwhogoestothemedicalinsuranceinstitutiontoreimbursethemedicalexpensesincurredbyhimselforherselfshouldgenerallymeetthefollowingconditions:
(1)Participantsmustgotothedesignatedmedicalinstitutionofthebasicmedicalinsurancetopurchasemedicines,orpurchasemedicinesfromthedesignatedretailpharmaciesdeterminedbythesocialinsuranceinstitutionwithamedicalprescriptionissuedbythedoctorofthedesignatedhospital.
(2)Themedicalexpensesincurredbytheinsuredpersonintheprocessofseeingadoctormustmeetthescopeandpaymentstandardsofthebasicmedicalinsuranceinsurancedrugcatalog,diagnosisandtreatmentitems,andmedicalservicefacilitystandardsinordertobecoveredbythebasicmedicalinsuranceThefundpaysaccordingtoregulations.
(3)Amongthemedicalexpensescoveredbythebasicmedicalinsurancefortheinsuredpersons,theexpensesabovethethresholdofthesocialmedicalpoolingfundandbelowthemaximumpaymentlimitwillbepaidbythesocialmedicalpoolingfundinauniformproportion.
Коефициент на възстановяване
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.Хоспитализация.
Youcanonlyenjoymedicalinsurancereimbursementafterretirementfor20yearsofmedicalinsurance.
Thescopeofthereimbursementratioofmedicalinsurancevariesfromplacetoplace.Pleaserefertolocalpoliciesandregulationsfordetails.
Китайската система
Създаване и развитие
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.
Законови разпоредби
Глава трета Основни медицински застраховки
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) Тези, които трябва да бъдат изплатени от фонда за застраховка за злополука, свързана с работата;
(2) Трябва да се носи от трето лице;
(3) Трябва да се носи от общественото здраве;
(4) Потърсете медицинско лечение в чужбина.
Medicalexpensesshallbebornebyathirdpersoninaccordancewiththelaw.Ifthethirdpersondoesnotpayorthethirdpersoncannotbeidentified,thebasicmedicalinsurancefundshallpayfirst.Afterthebasicmedicalinsurancefundhaspaidinadvance,ithastherighttoclaimcompensationfromathirdparty.
Article31Accordingtotheneedsofmanagementservices,socialinsuranceagenciesmaysignserviceagreementswithmedicalinstitutionsandpharmaceuticalbusinessunitstoregulatemedicalservicebehaviors.
Medicalinstitutionsshallprovidereasonableandnecessarymedicalservicestotheinsuredpersons.
Article32Ifanindividualisemployedacrossacoordinatedarea,hisbasicmedicalinsurancerelationshipwillbetransferredwiththeindividual,andthepaymentperiodwillbecalculatedcumulatively.
ReformTrends
AccordingtothewebsiteoftheMinistryofHumanResourcesandSocialSecurity,theMinistryofHumanResourcesandSocialSecurityandtheMinistryofFinanceissuedthe"NoticeonthePhasedReductionofSocialInsuranceRates".The"Notice"statedthatThecombinedimplementationofmaternityinsuranceandbasicmedicalinsurancewillbeorganizedandimplementeduniformlyaftertheStateCouncilformulatesandissuesrelevantregulations.
Въведение в операциите
Управление на профила
(1) Създаване на лична сметка
SocialmedicalinsuranceagenciesprovideforeachinsuredpersonCreateapersonalaccountforbasicmedicalinsuranceanduseyourIDnumberasyourlifelongmedicalinsurancenumber.Thefundsinthepersonalaccountofthebasicmedicalinsuranceforemployeesareownedbytheindividualandusedformedicalconsumption.Whentheemployeedies,hispersonalaccountshallbecancelled,andthebalanceshallbeinheritedaccordingtoregulations.
(2) Издаване на лична сметка
Theemployershallapplyforthepersonalmedicalaccountsettlementcardfortheemployeewhileparticipatinginthebasicmedicalinsurance.Foremployeeswhonewlyparticipateinmedicalinsurance,within30daysfromthedateofenrollment,theemployershallapplytothesocialmedicalinsuranceagencyandproviderelevantmaterials.Afterthesocialmedicalinsuranceagencyreceivestheemployer’sapplicationfortheestablishmentofanemployee’shousehold,itshallcarefullyreviewtherelevantmaterials,establishanindividualaccountfortheemployeewithin15days,andissueapersonalaccountsettlementcard.Injectfundsintoemployees’personalmedicalaccountsinatimelymanner,andaccrueinterestinaccordancewithrelevantregulations.Retireeswhoareresettledindifferentplacesmaynotbeissuedcardsforthetimebeing.
Insuredpersonscanpurchasemedicinesatanydesignatedmedicalinstitutionordesignatedpharmacyinthiscoordinatingareawithapersonalmedicalaccountcard.Whenthefundsinthepersonalmedicalaccountareinsufficient,thepaymentshallbemadeincash.
(3) Прехвърляне и наследяване на лична сметка
Theinsuredpersonistransferredfromthelocalarea,andthefundsofthepersonalmedicalaccountwillbetransferredalongwithit.Ifthetransferisnotpossible,thebalanceofthepersonalaccountcanberefundedtome,andatthesametimeLogoffyourpersonalaccount.
Iftheinsuredpersondies,thebalanceofhispersonalaccountcanbeinheritedbyhislegalheir.
(4) Отчитане на загуби и преиздаване на карта с лична сметка
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.
Събиране на застрахователни премии
(1)Thecollectiondepartmentofthemedicalinsuranceinstitutionacceptsthe"MedicalInsurancePaymentBaseChangeReport"filledoutbytheinsuredunit,andrequiresthefollowinginformation:
1.График за изплащане на заплатите;
2."DetailedListofIncreaseandDecreaseofPersonsParticipatinginMedicalInsurance"
3.Otherinformationrequiredbythemedicalinsuranceagency.
(2) Одобрение на плащането
1.Thecollectiondepartmentofthemedicalinsuranceinstitutionshallreviewthepaymentdeclarationverificationformandrelatedmaterialssubmittedbytheinsuredunit.Afterpassingthereview,gothroughtheproceduresforverificationoradditionorreductionoftheinsuredpersonnel.
2.Thecollectiondepartmentofthemedicalinsuranceinstitutionshall,basedonthepaymentdeclarationandverificationstatus,promptlyrecordinformationsuchasthetimeofenrollmentandthecurrentpaymentsalaryforthenewlyinsuredpersons.Thecollectiondepartmentofthemedicalinsuranceinstitutionshallverifythecurrentpaymentbasebasedonthereportingstatusoftheinsuredunit.
3.Thecollectiondepartmentofthemedicalinsuranceinstitutioncalculatestheamounttobepaidbasedonthecurrentpaymentbaseandpaymentrateoftheapprovedparticipatingunit,andprintsoutthe"MedicalInsurancePaymentNotice"tofeedbackthereportingunit,andcollectitbasedonthis.
(3) Офиси за събиране
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) Компенсиране на просрочени задължения
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.
Процедури за сетълмент
Settlingproceduresforhospitalizationandoutpatienttreatmentofspecialdiseases
DesignatedmedicalinstitutionsBeforethe10thofeachmonth,submittheexpensestatement,hospitalizationstatementandrelatedinformationofthepatientsdischargedfromthehospitallastmonthtothemedicalinsuranceagency.Afterthemedicalinsuranceagencyreviews,itwillbeusedasthebasisformonthlyadvancesandyear-endfinalaccounts.Themedicalinsuranceagencypre-appropriatestheoverallplanningexpensesforhospitalizationandoutpatienttreatmentofspecialdiseasesinthepreviousmonth.
Insuredpersonswhohavebeenidentifiedassufferingfromspecialdiseasesshouldgotoadesignatedmedicalinstitutiondesignatedbythelaborandsocialsecuritydepartmentformedicaltreatmentandpurchasedrugs.Themedicalexpensesincurredaredirectlyaccountedforandsettledimmediately.
(2) Процедури за спешно уреждане
Insuredpersonsarehospitalizedinnon-designatedmedicalinstitutionsinthecityandremotemedicalinstitutionsduetoemergencytreatment,andthemedicalexpensesincurredshallfirstbepaidbytheindividualorTheunitpaysinadvance.Aftertheemergencytreatmentiscompleted,thehospitalemergencymedicalrecords,examinations,laboratorytestreports,invoices,detailedmedicalbills,etc.gotothemedicalinsuranceagencytogothroughthereimbursementproceduresinaccordancewiththeregulations.
(3)Процедури за сетълментforpeopleresettledindifferentplaces
1.Fortheworkerswhoareresettledindifferentplaces,theirunitsshalldesignate1-2designatedmedicalinstitutionsintheirplacesofresidenceandreporttomedicalinsurance.Thehandlingagencyfortherecord.
2.Themedicalexpensesincurredintheclinicofthedesignatedmedicalinstitutionintheplaceofresidenceoftheworkerswhoareresettledindifferentplacesshallbepaidinadvancebythepersonortheunit.Afterthetreatmentiscompleted,theunitshallholdthemedicalcertificateoftheinsuredpersonandMedicalrecords,validexpensereceipts,compoundprescriptions,hospitalizationexpenseslist,etc.shallbesettledatthesocialmedicalinsuranceagencyonthespecifieddate.
(4) Сетълмент за препращане и прехвърляне
1.Iftheinsuredpersonistransferredtoothermedicalinstitutionsfordiagnosisandtreatmentduetotheconditionsofdesignatedmedicalinstitutionsorspecialdiseases,areferralisrequiredTransferapprovalform.Thedoctorinchargeputforwardthereasonforthereferral,thedirectorofthedepartmentputforwardtheopinionofthereferral,themedicalinsuranceofficeofthemedicalinstitutionreviews,thedirectorinchargesigns,andthemunicipalmedicalinsurancecenterforapprovalcanbetransferred.
2.Inprinciple,referralisfirstinthecityandthenoutsidethecity,firstintheprovinceandthenoutsidetheprovince.Referralsinthecityarestipulatedtobecarriedoutamongdesignatedmedicalinstitutions.Referralsoutsidethecitymustbesubmittedbydesignatedmedicalinstitutionsatorabovethethirdlevelinthecity.
3.Themedicalexpensesincurredaftertheinsuredpersonistransferredshallbepaidincashbytheindividualororganizationfirst.Afterthemedicaltreatmentends,theinsuredpersonorhisagentshallholdthereferralandtransferapprovalformandmedicalrecordCertificates,prescriptionsandvaliddocumentsshallbereimbursedatthemedicalinsuranceagencyforhospitalizationexpensesthatfallwithinthescopeofpaymentbytheoverallplanningfund.
Процес на възстановяване
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.
Национална политика
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.
Пето, установете единна система за социално управление.
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?
Обезщетение за тежко заболяване:
(1)Townshipriskfundcompensation:Allinpatientsparticipatingincooperativemedicalcareshallbecompensatedinstagesforaone-timeorannualaccumulativereportablemedicalexpensesexceedingRMB5,000.Thatis,thecompensationof5001-10000yuanis65%,andthecompensationof10001-18000yuanis70%.
(2)Town-levelcooperativemedicalhospitalizationandoutpatienturemiaoutpatienthemodialysis,tumoroutpatientradiotherapyandchemotherapycompensationhaveanannuallimitof11,000yuan.
Компенсация за хоспитализация:
(1) Коефициент на възстановяване: 60% възстановяване на разходите за общински болници; 40% възстановяване на разходи за второстепенни болници; 30% възстановяване на разходи за третични болници.
(2) Обхват на възстановяването:
A.Медицински разходи: допълнителен преглед: ЕКГ, рентгенова флуороскопия, заснемане, лабораторни тестове, физиотерапия, акупунктура, CT, MRI и т.н. Всяка такса за проверка е ограничена до 200 юана; такса за операция (референтни стандарти, 1000 юана ще бъдат възстановени, но надвишава 1000 юана).
B.Elderlypersonsover60yearsoldarehospitalizedintownshiphealthcenters,andthetreatmentandnursingexpensesarecompensatedat10yuanperday,withalimitof200yuan.
Компенсации за амбулаторни клиники:
(1)60%reimbursementforclinicvisitsinvillageclinicsandvillagecenterclinics,prescriptiondrugfeelimitforeachvisitis10yuan,hospitaldoctors’temporaryrehydrationprescriptiondrugfeelimit50RMB.
(2)40%reimbursementformedicalvisitsinthetownshiphospital,eachexaminationfeeandsurgeryfeelimitis50yuan,prescriptiondruglimitis100yuan;secondaryhospitalvisits30%reimbursement,prescriptiondruglimitis200Yuan;20%reimbursementfortreatmentintertiaryhospitals,andalimitof200yuanforprescriptiondrugs.
(3)Chinesemedicineinvoicesareattachedwithaprescriptionlimitof1yuanperpost.
(4)Годишният лимит на компенсация на кооперативните медицински амбулаторни клиники на ниво град е 5000 юана.
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.
Местни политики
InNovember2019,Anhuiissuedthe"AnhuiProvinceBasicMedicalInsuranceGroupedPaymentGuidancePlanbyTypeofDisease(Trial)"tofullyimplementbasicmedicalinsurancetogroupbytypeofdiseasePay-basedpaymentmethod.Thefirstbatchof422diseasesandpaymentmethodswereannounced.StartingfromJanuary1,2020,urbanandruralresidentsmedicalinsuranceparticipantswillhaveaunifiedpaymentstandardwhentheyseekmedicaltreatmentin18provincialhospitals.
Мултирисково управление
Iftheinsuredconsumerpurchaseshospitalizationmedicalexpenseinsurancefromtwodifferentinsurancecompanies,thenwithintheinsuredamount,theinsurancecompanywillTheactualcostsituationiscombinedwiththeinsuredamounttocalculatetheclaim.Mostinsurancecompaniessetacertainamountofnocompensation.Ontopofthenocompensation,theinsurancecompanypaysaccordingtotheagreedratio.Afterthefirstinsurancecompanypays,thesecondinsurancecompanydeterminesreasonableexpensesbasedontheremainingamount.Makeapayment.Inshort,thetotalamountofcompensationpaidbyinsurancecompanieswillnotexceedthemedicalexpensesofinsuredconsumers.
Неразбиране на искове
Недоразумение1: 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.
Недоразумение 3: Когато сте млади, можете да купувате по-малко вземания, а когато сте стари, можете да купувате повече премии.
Infact,consumerscanplanforarainydaywhentheyareyounganddoagoodjobforlife.Whenplanningmedicalinsurance,paypremiumswhenyouareyoung,andyouwillhavenoworrieswhenyouareold.