Zhuhai City, the implementation of the difficulties of the masses medical aid
The first & nbsp; to further improve the medical assistance system, to protect the basic health rights and interests of the difficulties of the masses, according to the national and provincial laws and regulations and related policies, combined with the actual is formulated.
Article 2 the & nbsp; the measures referred to in medical assistance, refers to the difficulties of the masses after enjoy the policy of medical compensation, subsidies, relief and social medical donation and the personal approval of medical expenses pays part, give the appropriate proportion of aid.
As mentioned in the present Measures personal approved medical expenses refers to the municipal human resources and social security departments identified, payment limit within the scope of the the city's social basic medical insurance to pay medicine, diagnosis and treatment projects and facilities of medical treatment service costs.
Third eligible for the city residents, and participated in the basic medical insurance of the city, the city's household registration of medical assistance, the application of this approach.
Fourth medical assistance system to follow the following basic principles:
(a) the protection of basic medical interests.
(two) with the economic and social development level adaptation.
(three) convergence with other social security systems.
(four) classification management, classification aid.
(five) open, fair, convenient and efficient.
Fifth medical aid work to implement the territorial management, by the city, District, Town People's government.
With the social affairs management function of the economic function of the district government to perform duties of medical assistance.
Sixth City medical aid work leading group to co-ordinate the city's medical aid work, and is responsible for the approval of special medical aid applications, office located in the municipal civil affairs department.
District medical aid work leading group to promote and implement the medical assistance in the region, and is responsible for the audit of special medical assistance applications, the office is located in the District Civil Affairs department.
Article 7 The & nbsp; City medical assistance in the work leading group office can be entrusted to professional and social organizations, responsible for the provision of medical assistance medical expertise and business consulting, to carry out medical assistance investigation and evaluation system and so on.
; department responsibilities
Article 8 The & nbsp; City Civil Affairs Department (city medical assistance in the work leading group office) is the competent department in charge of the work of the city medical assistance, according to the organization and implementation of the city's medical relief work, perform the following duties:
(a) the development of the city's medical assistance policy.
(two) in conjunction with the financial department of the same level to prepare the annual budget for medical aid and to allocate medical aid.
(three) supervision and guidance of the district civil affairs departments for medical assistance.
(four) business training for medical aid workers.
Ninth district civil affairs departments (district medical aid work leading group office) is responsible for the area within the jurisdiction of medical assistance, to perform the following duties:
(a) in conjunction with the financial department of the same level to prepare the annual budget for medical aid and grant medical aid.
(two) approval of medical aid applications.
(three) application for special medical assistance.
(four) the conduct of the investigation of the object of medical assistance in violation of the present measures.
(five) guidance, management and supervision of medical aid work to the people's Government of the town (street).
(six) the report statistics and file management of the medical aid work in the area.
Tenth the people's Government of the town (street) to perform the following duties:
(a) receiving medical aid applications.
(two) review of medical aid applications.
(three) the list of applicants for public health care and investigation and verification of the results.
(four) verification of the family property and family income of the applicant for medical assistance in the area of the jurisdiction.
(five) management of medical aid at the corresponding level.
The people's Government of a town (street offices) agreed to by the Civil Affairs Department of the District, according to the actual needs of the provisions of paragraph (a) of paragraph (3) of paragraph (4), above, commissioned the work within the jurisdiction of the village (neighborhood) committees undertake.
Eleventh the financial sector to perform the following duties:
(a) with the civil affairs departments to develop medical relief standards.
(two) the implementation and examination of the budget and raise the level of medical aid.
(three) a review of the budget for the next year's medical aid budget proposed by the civil affairs department at the corresponding level.
(four) a review of the medical aid payment shall be paid by the civil affairs department.
(five) check and supervise the use of medical aid payment management, establish and improve the medical aid payment management system.
Twelfth human resources and social security departments to perform the following duties:
(a) to participate in the city's social basic medical insurance and realize the network settlement of medical expenses of the focus of relief object medical treatment to help the audit, payment and medical assistance gold financial accounting and other business handling work.
(two) medical aid information construction work.
Thirteenth health department is responsible for the guidance, supervision, regulation and supervision of the medical institutions of medical services.
Fourteenth the supervision and audit department is responsible for the supervision and inspection of the use of medical aid payment management.
Article 15 & nbsp; Red Cross, charities and other nonprofit social organizations, and actively carry out fund-raising activities, to carry out the individual actual burden of medical costs more than the government bailout of standard limit of permanent residents of the city and living in the foreign staff of the city of humanitarian medical aid work, the specific remedy by social organization self formulated and implemented.
Article 16 The & nbsp; public security (motor vehicle management, real estate registration, taxation, and financial departments according to the Civil Affairs Department of the query letters, in a timely manner to provide medical assistance applicant automobile, real estate, tax and other family assets and income and other relevant data and information.
The third chapter is medical relief object and relief standard
Seventeenth the medical rescue object referred to in this method is divided into the following two categories:
(a) the focus of the rescue object, refers to the following persons with the household registration of the city.
1 minimum living security object (hereinafter referred to as “ ”).
Town. No ability to work, no source of income and has no statutory maintenance, support and maintenance obligations, or the statutory maintenance, dependency, support obligations without maintenance, support, the ability to support the residents (hereinafter referred to as the town & ldquo; three & rdquo; object) and rural five objects.
3 leprosy patients.
(two) the basic object of relief, is to focus on the following conditions outside of the city residents and the city residents to participate in the basic medical insurance of the city, the city's household registration.
1 years of individual pay medical expenses more than 70% of their total household income.
2 total household property is not more than 2 times the maximum relief object of the relief object.
In one year, 2 people in the family members of the family and the people who were hospitalized for treatment, the annual personal self paid medical expenses can be combined.
Need long-term treatment (when the cumulative length of stay more than 2 months) poor people to apply for medical assistance, by the half of its total individual self paid medical expenses is more than 70% of the half the family income accounting, in line with the conditions of the relief phase to give medical assistance.
Eighteenth the focus of the relief object should be required to participate in the basic medical insurance, to participate in the city's urban and rural residents of the basic medical insurance individual payment by the government in full support.
Article 19 The & nbsp; standards of medical aid city civil affairs department jointly with the municipal finance, health, human resources and social security department according to the local economic and social development level and financial, and salvage object and project actual situation, in the light of urban and rural residents in the urban workers basic medical insurance and the relevant provisions of the formulation.
Twentieth according to the identity of the object of medical treatment and medical insurance, and other specific circumstances, respectively, according to the following criteria for medical assistance:
(a) the standard of medical aid for the relief object.
1. The focus of relief object after enjoy treatment of medical treatment insurance, the hospital approved medical expenses of the individual self paid part according to 100% relief (minimum target each hospitalization cost burden Qifubiaozhun 30%), but in the cumulative amount of aid does not exceed 3 million yuan.
During hospitalization rescue object, which belongs to the living object, urban & ldquo; three & rdquo; object, the object of rural five or leprosy patients of, can enjoy the entire hospital stay focus of aid targeted medical treatment to help.
2. The focus of relief object after enjoy treatment of medical treatment insurance, guaranteeing that the object of patient specific disease cost according to the individual pays 50% of the part to be relief the difference, but the annual aid to a total of amount is not more than 600 yuan; Urban & ldquo; three & rdquo; object, rural five guaranteed, leprosy outpatient individual pays part of the be a full rescue, but in the cumulative amount of aid is no more than 1200 yuan.
3 not to participate in the medical insurance of the focus of the relevant provisions of the relief object, according to the relevant provisions of the insured object standard implementation (including hospitalization and outpatient treatment).
(two) the standard of medical aid for basic aid.
1. With bailout conditions of the city household demobilized cadres in enterprises, municipal model worker of above, moral model, courageous, poverty alleviation relief personnel, supported edges personnel, civil affairs departments identified key entitled groups the hospital approved personal medical expense pays part by 100% of the rescue, but in the cumulative amount of aid does not exceed 3 million yuan.
2. Participate in the medical insurance of other basic relief object, enjoy treatment of medical treatment insurance, the hospital approved medical expenses according to the individual pays 80% be relief the difference, but the annual aid to a total of amount does not exceed 3 million yuan.
3. Did not participate in the medical insurance of other basic relief object, the hospitalization expense according to the relevant provisions of the health insurance approval, according to the individual pays 50% of the part to be the difference between the rescue, but in the cumulative amount of aid is not more than 20000 yuan.
Article 21 The & nbsp; outside the city in social basic medical insurance of permanent residents of the city, and to permanent residents of the city's social basic medical insurance, enjoy the same medical assistance treatment.
Fourth chapter application and approval
Article 22 The & nbsp; participated in the assistance focused on the social basic medical insurance, by the proof of my identity card, social security card, and the Ministry of civil affairs of the child welfare card ", Guangdong Provincial Civil Affairs Department of the" Five Guarantees "card", the Zhuhai City minimal assurance relief Jinling evidence "or district level civil affairs departments (social welfare institutions), directly in the medical treatment of the city medical insurance designated medical service institutions for medical expenses relief.
Basic relief object and did not participate in the assistance focused on the social basic medical insurance to the city medical insurance designated medical service institutions for medical treatment or object in the outside medical assistance, by individuals after the payment of medical expenses, to account for the location of the town people's Government (street offices) for medical assistance.
Article 23 The & nbsp; included in the scope of the family property including cash, bank savings, stocks, funds, bonds, the car, non owner occupied housing, and calligraphy, ancient coins, porcelain and other antiques and gold, silver and other precious metals, stamps, currency, and other collectibles.
Twenty-fourth not included in the family property range:
(a) family housing (limited to 1 sets).
(two) the production of motorcycles, special vehicles for the disabled.
(three) the family property shall be determined by the municipal and district civil affairs departments.
Article 25 & nbsp; permanent residents of the city to apply for medical assistance, by the applicant to account for the location to the people's Government of the town (street offices) apply, fill out the "Zhuhai City medical assistance payments for approval form", and submit the following information according to the different circumstances of the applicant's family:
(a) data on family income: proof of income of family members, family members have labor ability but not employment, should provide proof of unemployment card or a public employment service agency issued by the registration of the unemployed; students in reading proof; complete loss or lose most of their ability to work in the proof; disabled card.
(II) family property data: the provisions of Article 23, Article 24 provides property proof material; within the scope of the city residence where they are residing in should be to provide proof of family income and property issued by the current place of residence in the town people's Government (street offices).
(three) the identity card or residence booklet and a copy of the original and the copy of the application for the other person, at the same time provide the client's identity card or residence booklet.
(4) the relevant medical institutions issued a certificate of disease, medication or treatment programs list, proof of referral, referral notice and medical cost effective instruments.
(five) the enjoyment of the urban residents (workers), such as medical insurance policy compensation, subsidies.
(six) the receipt of social medical donations.
(seven) an accidental injury medical expense, which is not determined by any other person or person responsible person, is described by a person in writing of the injury process.
(eight) other information to be provided.
Focus on the application of medical aid to the object can not provide family income and family property related information.
Applicants for the need for referral to non designated medical institution or outside of medical institutions should be issued by the city three Jiadeng hospital to provide proof of referral (hospital disease specialist was published by the municipal human resources and social security departments with turn diagnosis qualification certificate), by the relief object reported to the district civil affairs departments approved the registration.
The applicant for special circumstances of different places, should provide the city social insurance agency issued by the remote medical certificate or medical institution of the emergency certificate.
Article 26 The & nbsp; the people's Government of a town (street offices) shall be from the acceptance of materials, from 2 days will be the basic information of the applicant in the account applicant is located or the current place of residence posting publicity, publicity period for 5 days.
Any unit or individual to raise objections to the applicant, Town People's Government (street offices) to deal with objections verification, at the expiration of the publicity on the 5th to make treatment decisions, and the results will inform the objections to the units or individuals is proposed.
Objection processing time is not included in the town people's Government (Street Office) of the investigation and verification time.
Town People's Government (Street Office) should be within the period of 5 days after the expiration of the applicant's family income, family property, etc..
The applicant household location and current residence not in the same town people's Government (street offices) within the jurisdiction, the admissibility of the application Town People's Government (street offices) entrusted the applicant's current place of residence of the town people's Government (street offices) to assist in the investigation. The people's Government of the town (street), which is under the assistance of the Commission, shall complete the investigation within 5 days.
In line with the conditions of application, the people's Government of the town (street offices) shall sign opinions and report to the district civil administration department for examination and approval within 2 days; does not meet the eligibility criteria, the people's Government of the town (street offices) shall be the results to inform the applicant in writing, and explain the reasons.
Article 27 The & nbsp; district civil affairs departments should be within 5 days from the date of receipt of the audit materials delivered by the people's Government of the town (street offices), for approval, and the results of examination and approval shall notify the applicant in writing and the people's Government of the town (street offices). Which is not approved, to explain the specific reasons.
Article 28 The & nbsp; non personnel of this city census register to apply for medical assistance, the applicant should refer to the provisions of Article 25 to provide proof of relevant information and account located at the county level or above the Civil Affairs Department issued by the effective guarantee low or family income, the family property, to the unit or place of residence of the district civil affairs departments to apply.
District civil affairs departments should be self received medical assistance for all the materials, investigation, verification, assessment within 20 days of the applicant on the situation, make a decision on examination and approval, and approval of the written notice to the applicant, which not to grant the approval, to explain the specific reasons.
Zhuhai free trade zone (including the cross-border industrial zone in the Pearl Bay) of migrant workers to apply for medical assistance, and its application and approval procedures for the reference of other economic functions.
Article 29 The & nbsp; the applicant to enjoy treatment of medical treatment insurance and cumulative maximum medical assistance after treatment, because of special hardship families still unable to bear the medical expenses, to the Red Cross, charity organizations and other social application medical assistance, or apply to the district civil affairs departments (district medical relief work leading Group Office of special medical assistance, fill in the Zhuhai special medical assistance payments for approval form ", and in the light of the provisions of Article 25 of submitted to the relevant information.
District civil affairs departments (district medical relief work leading group office) after receiving special medical assistance for all the information within 10 days of the applicant to investigate and put forward opinions and the district medical relief work leading group audit the evacuation of the city civil affairs department (city medical assistance in the work leading group office).
City Civil Affairs Department (city medical assistance in the work leading group office) self audit materials received area delivery, up on the 5th of the relief to the special medical application for review, and put forward the views submitted to the municipal medical assistance work leading group for approval.
Special medical assistance for the examination and approval of the results of the district civil affairs departments (district medical aid work leading group office) written inform the applicant.
Article 30 the & nbsp; applicant cannot on their own to the application, by the guardian (kinship) or unit, where the account Village (neighborhood) people on behalf of the Commission to apply for; is a town & ldquo; three & rdquo; object, rural five guaranteed, the lepers of the applicant, on behalf of the village (neighborhood) committees or support of social welfare institutions, from leprosy hospital for.
The fifth chapter medical aid payment audit settlement and payment
Thirty-first the settlement and payment of the medical aid payment of the object.
(a) to participate in the medical insurance key aid in the city medical insurance designated service medical treatment, drugs, medical expenses, in accordance with the medical insurance related provisions of networking and clearing, the approved medical expenses pays part of the salvage value is calculated according to the rescue of identity and standards of medical aid, the municipal social insurance agency orgnaization pay and the rest by the patient payment.
(two) the financial burden of the medical aid payment of the medical insurance fixed services institution of the municipality is a financial burden. City Department of finance to a certain amount of medical assistance for gold pre allocated to the municipal social insurance agencies & ldquo; medical assistance payments expenditure account & rdquo; and according to the medical assistance fund use timely disbursement of funds.
(three) the settlement, payment and financial burden of medical insurance or medical insurance or other medical care in different places are the reference to the implementation of the basic rescue object.
Thirty-second the settlement and payment of the basic aid object medical aid and special medical relief fund.
(a) basic relief medical rescue gold, special medical assistance payments in accordance with the provisions of Chapter IV of the examination and approval procedures, the District Civil Affairs, the financial sector since the approval of medical assistance, from within 10 days will be medical assistance payments through banks directly included in the submitted by the applicant's Bank account.
(II) basic relief medical aid and relief to the special medical gold by the District, the town of financial burden. The specific proportion determined by the district and town financial difficulties, by the district fiscal transparency; city finance every quarter by the district medical assistance payment of 40% to give subsidies.
(three) District civil affairs departments in each quarter summary medical aid expenditures were filled out, the Zhuhai City medical aid Gold Fund summary tables and the Zhuhai special medical rescue gold fund summary table ", reported to the municipal civil affairs, finance department.
Every quarter of the city Department of finance to transfer payments to municipal medical aid grant funds allocated to the district medical rescue the financial accounts.
Thirty-third the following situation is not paid for medical aid:
(a) not to go through the relevant procedures, to non fixed medical (service) institutions or to buy drugs on their own (emergency, rescue).
(two) medical (service) institutions at the expense of the relevant policy.
(three) medical expenses beyond the scope of the basic medical insurance, medical treatment, medical service facilities, etc..
(four) medical expenses paid by various insurance.
(five) the medical expenses of the relevant units or departments.
(six) the community has been helping the medical expenses.
(seven) the medical expenses of the applicant's own or the unit of the family for their reimbursement.
(8) belongs to other responsible person should bear part of the responsibility, but the following situations can to give first aid, should bear the medical expenses to be responsible for payment, the applicant should be in a timely manner to the medical assistance to the examination and approval authorities returned medical assistance payments:
1 the injured party fails to get compensation after the judicial enforcement procedure.
6 public security, criminal, traffic accidents and other cases 2 months after the filing failed to identify the responsible person.
(nine) the person deliberately caused by medical expenses, such as the Dutch act, self injury (except mental illness).
(ten) the medical expenses incurred by the injury.
Article 34 The & nbsp; Article 33 (2), (3) item involved medical expenses, by medical insurance designated medical service institutions in the medical expense examination directly deducted; the (4) to (8) involved in medical expenses, by the applicant in the application of medical assistance to take the initiative to declare.
Sixth chapter medical management and information system update
Thirty-fifth medical care for the medical care services, and the city's social basic medical insurance system, the medical insurance designated medical service (service) institutions.
Medical insurance designated medical service institutions in principle according to the city's social basic medical insurance provisions of basic drugs directory, diagnosis and treatment project directory and facilities of medical treatment service directory, develop medical aid service standards, provide Limin, convenience measures, reduce the cost of medical service.
Article 36 The & nbsp; focus of relief object according to its in the social basic medical insurance of the relevant provisions of medical treatment and should be initiative to medical insurance designated medical service institutions provide to meet the conditions of medical assistance relevant certificates or proof. Approved medical insurance designated medical institutions should focus on the relief of the object identity, free of the hospital deposit (deposit), arrangement of loving wards in accordance with the relevant provisions, reduction of medical expenses.
Thirty-seventh medical insurance designated medical institutions shall not refuse to accept the object of emergency critical care in any reason.
Article 38 The & nbsp; focus of relief object to achieve discharge conditions and refused to discharge, since the municipal social insurance agencies issued discharge notice. What happened all medical expenses shall be borne by the individual.
Article 39 The & nbsp; district civil affairs departments, Township People's Government (street offices) shall will focus on relief object information in accordance with the provisions of the record format & ldquo; Zhuhai City Social Security Information System & rdquo; of & ldquo; minimum target management & rdquo; subsystem and strengthen dynamic management. Key relief objects appear to change, should be in their capacity to change the identity of 10 days to change procedures, update information system data.
Article 40 The & nbsp; city social insurance agencies according to & ldquo; minimum target management & rdquo; effective data subsystem, in insured person basic information database of the focus of relief object with identity, and is updated in real time, modify corresponding identification.
Seventh chapter safeguard measures
Forty-first city, district finance separately set up special funds for medical aid, medical aid:
(a) at all levels of the financial year according to the local urban and rural residents minimum living standard of the people's health protection standard 14% of the proportion of the budget arrangements for medical aid.
(two) according to the welfare lottery. The local part of the proportion of 20% for medical assistance funds.
(three) the medical aid fund for the higher level.
(four) funding for medical assistance from various sectors of the society.
(five) medical aid funds at all levels of financial supplementary arrangements.
(six) interest income on the formation of medical aid funds.
(seven) other funds.
Forty-second city, district finance department to set up the medical assistance fund accounts, separate accounting, special management. Municipal social insurance agencies to establish medical assistance payments, accounting for medical aid funds, responsible for the medical insurance and medical insurance designated medical institutions for medical assistance.
Article 43 The & nbsp; medical assistance funds must be earmarking, and not from the extraction of management fees or any other fees charged. That year the balance of funds to continue to use the next year.
Forty-fourth governments at all levels should earnestly fulfill the medical aid management responsibilities, the deployment of relevant institutions and personnel, responsible for the medical treatment of the audit, payment and other work.
Forty-fifth medical aid information system development and maintenance, and other related work included in the budget.
Eighth chapter legal responsibility
Article 46 The & nbsp; medical aid applicants take misrepresentation, concealment, forgery and other means, defrauding aid and not timely return of giving first aid medical assistance of gold, by the District Civil Affairs Bureau to give criticism and education, recover the impersonator or should be returned to the aid, cancel the qualification of the medical assistance; if the circumstances are serious, shall be investigated for legal responsibility; suspected of a crime, shall be transferred to the judicial organs.
Medical insurance fixed point medical (service) institutions have to cheat the medical aid payment and other fraud, by the relevant authorities in accordance with the law.
Article 47 The & nbsp; state organs, enterprises and institutions, social organizations, village (neighborhood) committees and other social organizations, do not provide the applicant's family income, property and other relevant circumstances, by the district civil affairs departments to draw the competent authorities at a higher level or the relevant department shall be dealt with in accordance with laws and regulations and the relevant provisions, and included in the people's Bank of enterprise and personal credit information database and the relevant departments to establish the integrity of the system.
Article 48 The & nbsp; engaged in medical assistance to the relevant departments and their staff have one of the following acts, by the superior organ or the competent organ or unit shall be ordered to make corrections, shall be punished according to law; constitute a crime, shall be investigated for criminal responsibility:
(a) not to accept the application for medical assistance, or not to accept the reasons for the refusal of the law.
(two) the application of the medical aid condition is not to sign an agreement, or to approve an application for a medical aid condition.
(III) dereliction of duty, corruption, misappropriation, withholding, arrears, false medical assistance payments, allowed to raise or lower the level of medical assistance.
Article 49 The & nbsp; city and district civil affairs departments and the people's Government of the town (street offices) shall be the medical assistance policies, procedures, medical aid payment situation to the public, and the establishment of medical assistance to the complaints, telephone hotlines. Acceptance of complaints from the admissibility of the complaint, from the date of 30 days after the investigation is completed, and will handle the results to inform the complainant, informants.
Article 50 the & nbsp; medical assistance to the applicant or the relevant parties to apply for medical assistance will not be accepted, refuses to accept the results of the examination and approval and administrative punishment, according to law, apply for administrative reconsideration, the administrative reconsideration refuses to accept the decision, can bring an administrative lawsuit.
;
Fifty-first the annual social security year as mentioned in the present Measures shall, on the date of the work day.
Fifty-second medical insurance, as described in the present measures, the basic medical insurance of this Municipality shall not have any special instructions. Including: basic medical insurance for urban workers, urban and rural residents basic medical insurance, basic medical insurance for minors, the health insurance of migrant workers.
Fifty-third implementation of the implementation of the implementation of the implementation of the July 1, 2011, Zhuhai City, the implementation of urban and rural medical assistance (2007) (140) at the same time to abolish.
Fifty-fourth this approach by the Zhuhai Municipal Civil Affairs Bureau, responsible for interpretation.