On the issuance of the &”;basic medical insurance for urban residents in Guangzhou&”;
Notice of the detailed rules for the implementation
Sui Lao She Yi [2008] No.7
All districts, county-level cities and relevant units:
According to the authorization provisions of Articl《广州市城镇居民基本医疗保险试行办法》 (Sui Fu Ban [2008] No.22), th《广州市城镇居民基本医疗保险实施细则》. It is issued to you, please follow it.
Guangzhou Municipal Bureau of Labor and Social Security
July 18th, 2008
(Undertaking Office: Medical Insurance Office,)
Detailed rules for the implementation of basic medical insurance for urban residents in Guangzhou
According to 《广州市城镇居民基本医疗保险试行办法》 (Sui Fu Ban [2008] No.22, h《试行办法》), these Detailed Rules are formulated.
First, the insurance registration and payment
(1) Handling of insurance registration business
The departments of labor and social security, civil affairs, disabled persons&; federations and education in all districts shall set up insurance registration points in each street (town) labor and social security service center, civil affairs office, disabled persons&; federations, kindergartens and schools within their respective jurisdictions according to the distribution of residents&; residence. Urban residents (hereinafter referred to as &”;residents&”;) in the medical insurance co-ordination area of this Municipality (including Yuexiu District, Haizhu District, Liwan District, Tianhe District, Baiyun District, Huangpu District, Nansha District and Luogang District) shall go through the insurance registration procedures as follows:
Minors (residents before June 1 of that year), non-employed residents and elderly residents with urban household registration in this Municipality shall go through the insurance registration formalities at any street (town) labor security service center in this Municipality by themselves or their agents;
Students who are officially registered in all kinds of schools in this city, and minors with urban household registration in kindergartens in this city shall be registered by their schools and kindergartens in a unified manner;
Among the above-mentioned residents, the minimum living security object, low-income families with difficulties, and the support personnel accommodated by social welfare institutions in this city shall go through the registration formalities at the social affairs (civil affairs) office of their respective streets (towns).
The severely disabled people in this city shall go through the insurance registration formalities with the disabled persons&; Federation department in their street (town).
(2) Insuranc《广州市城镇居民基本医疗保险参保申报表》, with th:.
(1) Non-employed residents, elderly residents and full-time students in various institutions of higher learning, secondary vocational and technical schools and technical schools shall provide the original and photocopy of the household registration book and ID card (the photocopy of the household registration book includes the first page of the household name and the page of the insured person, the same below);
(2) Minors and full-time students in primary and secondary schools shall provide the original and photocopy of the household registration book, and the newborn within three months after birth shall also provide the original and photocopy of 《出生证》;
(3) Foreign students should provide the original and photocopy of their passports when applying for insurance;
2. If the insured chooses to entrust a bank to remit medical insurance premiums to residents, he/she shall provide the passbook and photocopy of the designated bank, the original and photocopy of the passbook owner&;s ID card, and fill in and sign th《委托银行自动转账付款缴纳社会保险费授权书》 in the prescribed format. Did not handle the entrusted bank sinceThe insured registration personnel who go through the transfer payment procedures shall go to the municipal local tax department to entrust the bank outlets to pay the fees.
3, the following residents in addition to providing the above information, but also need to provide the corresponding information:
(1) low-income families with difficulti《广州市低收入困难家庭证》;
(2) 《广州市城镇居民最低生活保障金领取证》 should be provided for the urban minimum living security target personnel;
(3) The rural minimum living security targ《广州市农村居民最低生活保障金领取证》;
(4) P《残疾人证》.
(3) Collection and review of residents&; personal information
Each street (town) labor and social security service center is responsible for minors, non-employed residents and elderly residents, nursery institutions are responsible for their nursery children, and schools are responsible for the collection and verification of their students&; personal insurance information, and send the insurance registration data to the local social insurance fund management center for review every week; The district social insurance fund management c《广州市城镇居民基本医保个人征缴核定单》 (h《核定单》) within 10 working days after receiving the information, and then distribute it to the insured by the above-mentioned insurance registration institution.
The civil affairs departments of each street (town) are responsible for the collection, verification and preliminary examination of the personal information of the insured registered by them, and submit them to the District Civil Affairs Bureau for review before the 20th of each month; The Civil Affairs Bureau of each district will send the results of the examination of the insured person&;s individual funding qualification to the local social insurance fund management center before the 23rd of each month; The district social insurance fund management c《核定单》 within 10 working days after receiving the information, and then the civil affairs departments of each str《核定单》 to the insured.
Each street (town) disabled persons&; Federation department is responsible for collecting and checking the insured information of severely disabled persons. After the preliminary examination of the insured person&;s individual funding qualification, it shall be submitted to the district disabled persons&; Federation department for review before the 15th of each month. District Disabled Persons&; Federation Department shall review and summarize before the 20th of each month and submit it to the District Civil Affairs Bureau, which will send the results of reviewing the insured person&;s individual funding qualification to the local social insurance fund management center before the 23rd of each month; The district social insurance fund management c《核定单》 within 10 working days after receiving the information, and then the disabled persons&; Federation departments of each str《核定单》 to the insured.
For the insured who refuses to accept the insurance registration and fails to pass the examination, the insurance registration departments shall issue a notice of not participating in the residents&; medical insurance.
Residents whose family members are responsible for the management of the provincial, municipal and district medical management departments are not insured for the time being.
On the last 2 working days of each month, the insurance registration institutions shall suspend the acceptance of insurance registration business.
(four) the beginning and ending time of the insurance year.
Residents&; basic medical insurance premiums are collected annually. Take July 1st of that year to June 30th of the following year as an insurance year.
The establishment of a medical insurance relationship after the registration of residents&; insurance is valid within this insurance year.
(5) Collection of insurance premiums
The basic medical insurance premium for residents shall be entrusted by the local tax department to the bank for collection. The specific business on behalf of the tax authorities and banks signed an agreement on behalf of the tax authorities to be clear.(six) payment method and payment period
Residents who have registered for insuranc《核定单》 to the collection unit entrusted by the local tax department within the prescribed time limit. Among them, the residents who are insured for the first time will pay the fee on the 3rd to 23rd of the month following the registration, and the residents who are insured continuously in the new year will pay the fee on the 3rd to 23rd of June each year.
The personnel who are funded by social medical assistance funds shall be paid as the insured by the Civil Affairs Bureau&;s examination and confirmation of the funded object and the amount of social medical assistance funds.
(seven) the collection of basic medical insurance premiums for residents.
The residents&; basic medical insurance premium levied by the local tax department shall be remitted in full to the financial accounts of the residents&; basic medical insurance fund in the current month, and shall be reconciled regularly with the municipal social insurance fund management center (hereinafter referred to as the municipal fund center), the municipal medical insurance service management center (hereinafter referred to as the municipal medical insurance center) and the municipal finance bureau.
The municipal fund center will send the data report of social medical assistance fund to the Municipal Civil Affairs Bureau before the 10th of each month, and the Municipal Civil Affairs Bureau will send it to the Municipal Medical Insurance Center before the 20th of that month after examination and confirmation.
City fund center approved at all levels of personal contributions to the insured and social medical assistance funds should be funded, sent to the city medical insurance center. City medical center monthly summary of all levels should be funded and social medical assistance should be funded, apply for funding to the Municipal Finance Bureau, according to the annual liquidation.
City Finance Bureau will be at all levels and social medical assistance funds should be funded into the basic medical insurance fund financial accounts. The Civil Affairs Bureau, the Municipal Medical Insurance Center and the Municipal Finance Bureau regularly reconcile.
Second, the insured changes, data changes
(eight) renewal procedures
Those who have participated in residents&; medical insurance do not need to re-apply for insurance registration in the new year. After paying the basic medical insurance premium for urban residents in accordance with the regulations, their medical insurance benefits will be automatically extended.
(9) Procedures for stopping insurance.
Need to stop the relationship between residents&; medical insuranc《城镇居民基本医疗保险停保登记表》, and go through the formalities of stopping insurance at the affiliated insurance registration department before the end of May of that year.
If the insured fails to declare the termination of insurance before the end of May of that year, and fails to pay the fee in the new year, the insurance will be automatically terminated after the end of the new year.
(10) Handling of data change
If the basic information such as the name, ID number, household registration and personal identity of the insured person needs to be changed, it is nec《广州市城镇居民基本医疗保险个人资料变更表》 and go back to the original insurance registration department for the change.
Kindergarten children, school students and other insured people leave the park, graduate, transfer, new year&;s enrollment, etc., and continue to participate in residents&; medical insurance in the new year. If the basic information needs to be changed, the nursery institution or school shall go through the change procedures at the social insurance fund center in the district.
Third, the insurance certificate management
(eleven) the management of social medical insurance card
Guangzhou urban residents&; medical insurance card (hereinafter referred to as &”;residents&; medical insurance card&”;), as a certificate for the insured to seek medical treatment and handle medical insurance related business, is managed by the municipal medical insurance center. Residents&; medical insurance cards shall be handled with reference to the issuance of medical insurance cards for urban workers in Guangzhou.
The resident medical insurance card has the financial function of ordinary savings card.
Street (town) labor security service institutions, child care institutions, schools, district civil affairs departments, and district disabled persons&; federations are participating in the insurance.After the 19th day of the month following the first insured registration, people will receive the residents&; medical insurance card from the medical insurance agency in the district where the bid site is located with relevant information, and distribute the medical insurance card to the insured who has paid the fee in the current month before the end of the month.
(twelve) the use of social medical insurance card
The residents&; medical insurance card is only used by the insured person, and may not be lent to others. The medical expenses arising from illegal use shall be borne by the insured person after verification.
During the period when the resident medical insurance card is lost or duplicated, the resident medical insurance card shall be replaced by the loss reporting certificate or the re-printed receipt.
(13) the effectiveness of the insurance certificate
The insured to the designated medical institutions for medical treatment, must produce a valid medical insurance certificate and valid identity documents; Before presenting a valid medical insurance certificate, all the medical expenses incurred by medical treatment shall be borne by the insured.
If the insured person is admitted to the hospital in emergency or can&;t produce the medical insurance certificate on the spot due to coma and other unconsciousness, his relatives shall go through the formalities of showing the certificate within three working days of his admission.
When the insured person goes through the hospitalization registration due to the birth and termination of pregnancy in line with the family planning policy, he must also present the original valid documents approved by the family planning department.
Fourth, medical manag《居民医保门诊病历》 and 《异地就医记录册》.
《广州市社会医疗保险门诊病历》 (h《居民医保门诊病历》) and 《广州市社会医疗保险异地就医记录册》 (h《异地就医记录册》) are uniformly printed by the municipal medical insurance center. When the insured person goes to the designated medical institutions in this city for medical treatment, he/she will buy it at the price stipulated by the price department and keep it for himself. The specific measures for use shall be formulated separately by the municipal medical insurance center.
(fifteen) hospital, outpatient specific projects and designated chronic disease outpatient medical management.
The medical management of residents&; medical insurance insured persons in the designated medical institutions in this Municipality for hospitalization and outpatient specific projects and designated chronic disease treatment shall be implemented in accordance with the relevant provisions of the medical insurance system for employees in our city.
(sixteen) general outpatient (emergency) medical management.
General outpatient (emergency) consultation refers to outpatient specific items and outpatient (emergency) consultation outside the designated chronic disease clinic.
In the designated social insurance medical institutions that can use the city&;s medical insurance information system to keep accounts of outpatient (emergency) medical expenses, students and minors at school choose a community health service institution (except the community medical institutions with secondary and tertiary medical institutions in their headquarters, the same below) or the medical institutions of their school and one other medical institution, and elderly residents choose a community health service institution as the selected medical institution for outpatient (emergency) medical treatment.
Students and minors in school can enjoy the prescribed treatment when they go to the designated hospital for outpatient (emergency) treatment of corresponding specialized diseases. The specific designated hospitals and specialties shall be announced separately by the Municipal Medical Insurance Center.
In each social security year, the insured shall go through the formalities of confirming the selected medical institution when the medical institution is to be selected for the first time for general outpatient (emergency) consultation. Th《普通门（急）诊选定医疗机构登记表》 in 《居民医保门诊病历》, and paste a recent one-inch color photo without a hat; After checking the information of the insured person, the medical institution shall affix a special label at the corner of the photo.Label; The insured person shall confirm the medical institution as the selected medical institution for the current year after the current medical treatment is settled.
After confirming the selected medical institution, it will not be changed during the year. However, if the insured person has registered permanent residence or the qualification of designated medical institutions changes, and minors and students transfer to other schools and other specific circumstances, they can go through the formalities for changing the selected medical institutions at the offices of the Municipal Medical Insurance Center.
(seventeen) management of medical treatment in different places.
1, the insured person in different places for medical treatment, according to th《试行办法》 to enjoy the corresponding basic medical insurance benefits for residents:
(1) Insured persons who have lived in the same different place in China for more than half a year and have gone through the long-term medical treatment procedures in different places have selected specific items for hospitalization and outpatient service of medical institutions and designated chronic disease treatment in different places;
(2) Referral to public medical institutions outside the city for hospitalization after approval;
(3) Being hospitalized or under observation in an emergency department in a different place;
(4) During the winter and summer vacations, during the period of suspension from school due to illness, the students returned to their registered residence, or were hospitalized in local public medical institutions, outpatient specific projects and designated chronic disease treatment or emergency.
The residents&; medical insurance fund will not pay the medical expenses incurred by medical treatment in different places that do not fall within the above scope.
2, residents&; medical insurance management of medical treatment in different places, with reference to the relevant provisions of the basic medical insurance for urban workers in this city.
For the insured who have lived in the same place in China for more than half a year, according to the management of long-term medical treatment in different places, they should go through the procedures of long-term medical treatment in different plac《异地就医记录册》, and standardize the information records of medical treatment in different places.
Other circumstances of medical treatment in different places, according to the temporary management of medical treatment in different places.
Five, residents&; medical insurance benefits
(eighteen) the scope and standard of treatment
The scope and standard of residents&; medical insurance benefits shall be implemented in accordanc《试行办法》.
The basic medical expenses incurred by the insured elderly residents in their selected medical institutions (emergency) for medical treatment shall be reimbursed by 50%;
Students and minors in school will be reimbursed by 70% for the basic medical expenses for general outpatient (emergency) clinics in their selected community medical institutions or their school medical institutions, and by 40% for the basic medical expenses for general outpatient (emergency) clinics in their selected other medical institutions, designated hospitals and specialties;
The general outpatient (emergency) medical expenses incurred by the insured person in accordance with the regulations shall be paid by the individual, and the insured patient shall pay directly to the designated medical institution for settlement; Belonging to the residents&; medical insurance fund, the designated medical institutions shall first keep accounts and then report to the municipal medical insurance center for settlement on a monthly basis.
The residents&; medical insurance fund will not pay the ordinary outpatient (emergency) medical expenses incurred by the insured in non-selected medical institutions or non-designated hospitals and specialties. However, during the winter and summer vacations of school students, or during the period of dropping out of school due to illness, field practice, etc., the basic outpatient medical expenses incurred in emergency treatment in public medical institutions in different places will be reimbursed by the residents&; medical insurance fund at a rate of 40%.
(nineteen) the treatment of cross insurance convergence.
During the period of participating in residents&; medical insurance, urban residents change to participate in medical insurance for flexible employees in cities and towns,In the paid year of residents&; medical insurance, they can continue to enjoy residents&; medical insurance benefits in the months when they are in the waiting period of medical insurance for flexible employees.
(twenty) the cumulative annual maximum payment limit.
In a social security year, if a resident changes the insurance coverage of social medical insurance with the change of identity, the medical expenses incurred during the period of participating in different insurance coverage shall be accumulated respectively, and the annual maximum payment limit shall be calculated respectively.
(twenty-one) payment period
The insurance payment period for urban residents to participate in residents&; medical insurance is not accumulated as the insurance payment period for participating in the basic medical insurance for employees in this Municipality.
VI. Fund Payment
(twenty-two) the scope and standard of fund payment
The scope of the residents&; medical insurance fund to pay the medical expenses of the insured shall be implemented in accordance with the relevant provisions of the drug list, diagnosis and treatment items, medical service facilities and payment standards of the basic medical insurance for urban workers in this Municipality.
In accordance with the provisions of the family planning policy, the hospitalization medical expenses incurred in the birth or termination of pregnancy shall be implemented in accordance with the scope of the maternity insurance medical expenses payment items and directories of enterprise employees in this Municipality and th《试行办法》.
(twenty-three) the fund does not pay.
In any of the following circumstances, the residents&; medical insurance fund will not pay the relevant medical expenses:
1, without approval, in Guangzhou social insurance designated medical institutions outside the medical institutions for medical treatment;
2, self-mutilation (except mental illness);
3, fighting, drinking, and other injuries caused by crim《治安管理处罚法》;
4. Identify traffic accidents, accidents, medical accidents or medical expenses paid by industrial injury insurance that have been borne by the other party;
5, in foreign countries or, Macao Special Administrative Region and the region for medical treatment;
6, other circumstances stipulated by the state, province and city not to pay.
Seven, designated medical institutions management and medical expenses settlement
(twenty-four) management of designated medical institutions
The management of designated medical institutions for residents&; medical insurance shall be implemented in accordance with the relevant provisions of the basic medical insurance system for urban workers in this Municipality, and the Municipal Medical Insurance Center shall sign supplementary agreements with the designated medical institutions.
(twenty-five) medical expenses settlement
The basic medical expenses incurred by the insured for hospitalization and outpatient specific projects and designated chronic disease treatment shall be settled according to the corresponding settlement of the basic medical insurance for urban workers in this Municipality.
The basic medical expenses incurred by students and minors and other insured persons in the designated medical institutions in this Municipality according to the regulations shall be settled according to the service items.
Students, minors and elderly residents in accordance with the provisions of the general outpatient (emergency) medical expenses, which belong to the medical insurance fund to pay, the hospital first to charge to an account, by the municipal medical insurance center and designated medical institutions according to the service items, &”;annual per capita limit&”; or &”;monthly average limit&”; and other settlement. The specific method is determined in the medical service agreement.
(twenty-six) retrospective treatment of medical insurance for residents.
The scope of retrospective treatment of residents&; medical insurance:
If the newborn is insured within 3 months (including 3 months) after birth and pays the annual resident medical insurance premium, the basic medical expenses incurred from birth to the month of payment;
Students in the school before October 31 of that year to pay insurance, from July 1 of that year to pay.The basic medical expenses incurred in the curr《试行办法》 (before August 23, 2008), the basic medical expenses incurred from July 1 of that year to the month of payment.
Settlement of retrospective treatment of residents&; medical insurance
1. The operation of &”;the patient pays the deposit first, and the hospital delays the settlement&”; is adopted for the retrospective treatment of hospitalization medical treatment.
Starting from July 1st, 2008, the designated medical institutions can charge a deposit equal to the hospitalization medical expenses after consultation with the insured patients when handling the discharge check-out for the registered inpatients in this city who have participated in or are ready to participate in the residents&; medical insurance but have not yet enjoyed the treatment.
After the discharged patients can enjoy the residents&; medical insurance benefits, from August 1, 2008, they will apply to the original inpatient medical institution for medical expenses accounting and settlement with the residents&; medical insurance card, valid identity documents, deposit receipt and discharge certificate.
Designated medical institutions shall, after inquiring and confirming the identity and treatment of the insured on the medical insurance information system, go through the formalities of admission registration and discharge settlement and immediately return the deposit equal to the medical expenses to be accounted for.
2, emergency observation and other outpatient specific projects within the validity period of examination and approval, the medical treatment of designated chronic diseases, according to the retrospective treatment of hospitalization.
3, general outpatient (emergency) medical treatment according to the retrospective &”;sporadic reimbursement by the selected medical institutions&”;.
Since October 31, 2008, the selected medical institutions have begun to accept the application for sporadic reimbursement of basic medical expenses for outpatient (emergency) clinics of the insured within the retrospective period of treatment.
The steps of sporadic reimbursement for outpatient (emergency) medical expenses for selected medical institutions ar《广州市城镇居民医疗保险门（急）诊医疗费用医保待遇追溯申请单》 (h《申请单》) at the selected medical institution where the original medical expenses occurred, and present the resident medical insurance card, valid identity certificat《医保门诊病历》, and submit the copy of the front and back of the resident medical insurance card, the original medical expense receipt (invoice) and the details of medical expenses.
The selected medical institution shall immediately review and confirm th《申请单》, and submit the receipt to the insured.
(2) The selected medical institutions shall collect the application materials of the retrospective treatment of residents&; outpatient (emergency) tr《广州市城镇居民医疗保险选定医疗机构门（急）诊医疗费用追溯申报汇总表》 (h《申报表》).
Selected medical institutions will send the zero-reported application mat《申请单》 to the municipal medical insurance center office every month to centrally handle sporadic reimbursement of outpatient (emergency) medical expenses.
(3) The municipal medical insurance center will directly transfer the expenses paid by the residents&; medical insurance fund to the individual bank settlement account of the insured&;s residents&; medical insurance card after accepting and reviewing the application materials of the residents&; outpatient (emergency) treatment.
(twenty-seven) cross social security annual settlement.
Cross-social security year continuous hospitalization and outpatient treatment for specific items shall be settled by stages according to the social security year, and the medical expenses incurred shall be accumulated separately according to the social security year, and only one hospitalization Qifubiaozhun shall be paid.
(28) Cross-insurance settlement
When the insured person is in hospital, medical insurance coverage will occur.In case of change (for example, residents&; medical insurance is changed to employees&; medical insurance, or employees&; medical insurance is changed to residents&; medical insurance), the settlement shall be handled by sections, and the medical treatment standard shall be calculated according to the relevant standards that should be enjoyed at the time of settlement, and only one hospitalization Qifubiaozhun shall be paid.
Eight, sporadic reimbursement of medical expenses
(twenty-nine) the scope of sporadic reimbursement of medical expenses.
The following expenses belong to the scope of sporadic reimbursement of medical expenses:
1, after approval, the insured is indeed due to illness emergency or rescue, as well as the special needs of the disease, in the city&;s social insurance designated medical institutions hospitalization or emergency observation occurred in line with the provisions of medical expenses;
2. Due to objective reasons, the basic medical expenses that have not been settled in the designated medical institutions and the designated medical institutions cannot make up the system settlement and have been paid by the insured;
3, residents&; medical insurance benefits within the scope of traceability by designated medical institutions for sporadic reimbursement of ordinary outpatient (emergency) diagnosis of basic medical expenses;
4, in accordance with the provisions of Article 17 of these rules, the basic medical expenses of the scope of medical treatment in different places.
(30) Sporadic reimbursement
The insured shall, from the date of settlement of medical expenses, carry the following information within 3 months and apply for sporadic reimbursement to the municipal medical insurance center.
1, the original resident medical insurance card and a copy of the front and back;
2. Detailed list of medical expenses (or manual record list certified by medical institutions);
3. Receipts or invoices for medical charges printed by the financ《医保门诊病历》 or 《异地就医记录册》 and other information.
In the case of complete information, the municipal medical insurance center will complete the examination and settlement within 40 working days and transfer the expenses paid by the residents&; medical insurance fund to the bank personal settlement account of the insured residents&; medical insurance card; If it is a difficult case or requires special circumstances such as on-site verification, it will take no more than 90 working days to complete the audit and settlement.
City medical insurance center to confirm the information is not full, should be a one-time inform the missing information; If the conclusion of non-payment is made after examination, the insured person shall be informed within 40 working days.
IX. Others
(thirty-one) social medical assistance management
Residents with difficulties confirmed by the civil affairs department shall enjoy social medical assistance according to the relevant provisions after enjoying the medical insurance benefits for residents. The specific measures shall be implemented according to the relevant provisions of the civil affairs department.
(thirty-two) the starting time and limitation of implementation
These rules shall come into force as of the date of promulgation and shall be valid for three years. Upon expiration, it shall be evaluated and revised according to the implementation.