Measures of Shanghai Municipality on the Basic Medical Insurance for Urban Employees

· Document Number：Order No.92 of the Shanghai Municipal People’s Government

· Area of Law： Health and Sanitation Insurance

· Level of Authority： Local Government Rules

· Date issued：03-28-2008

· Effective Date：12-01-2000

· Status： Effective

· Issuing Authority： Shanghai Municipality

Measures of Shanghai Municipality on the Basic Medical Insurance for Urban Employees
(Promulgated by Order No.92 of the Shanghai Municipal People's Government on October 20, 2000, and revised according to the Decision on Revising the Measures of Shanghai Municipality on the Basic Medical Insurance for Urban Employees promulgated by Order No.1 of the Shanghai Municipal People's Government on March 28, 2008)
Chapter I General Provisions
Article 1 These Measures are formulated according to the Program of Shanghai Municipality on Implementing the Decision of the State Council on Establishing the Basic Medical Insurance System for Urban Employees for the purpose of guaranteeing basic medical needs of employees.
Article 2 These Measures shall apply to urban enterprises, government agencies, public institutions, social organizations and private non-enterprise entities (hereinafter referred to as “employers”) within the scope of this Municipality, the basic medical insurance of their employees as well as the relevant administrative activities.
The “employees” as mentioned in these Measures include in-service employees, retirees and other insurance participants.
Article 3 The Shanghai Medical Insurance Bureau (hereinafter referred to as the SMIB) shall be the competent administrative department of this Municipality for basic medical insurance and be responsible for uniform administration of basic medical insurance of this Municipality. The medical insurance offices in all districts and counties of this Municipality (hereinafter referred to as the SMIB branch offices) shall be responsible for administration of basic medical insurance within their own jurisdictions.
The administrative departments of this Municipality for health, labor and social security, treasury, audit, drug supervision and civil affairs, etc. shall, based on their own functions, cooperate to do a good job in the administrative work on basic medical insurance.
The social insurance agency of this Municipality shall be responsible for collecting and paying medical insurance premiums.
The Shanghai Medical Insurance Affairs Center (hereinafter referred to as the “SMIAC”) shall be the medical insurance agency of this Municipality and be responsible for settlement and payment of medical expenses as well as administration of basic medical insurance individual accounts (hereinafter referred to as “individual medical accounts”).
Chapter II Registration and Payment of Premiums
Article 4 An employer shall, according to the provisions formulated by the SMIB, go through the registration formality for basic medical insurance at the designated social insurance agency; and a newly established employer shall go through the registration formality for basic medical insurance within 30 days after establishment.
If an employer is terminated or any of its basic medical insurance registration items is changed, it shall go through the cancellation or alteration registration formality at the original registration agency.
When the social insurance agency is going through the formality provided by any of the preceding two paragraphs of this Article, it shall conduct examination and verification as required by the SMIB, and timely notify the information about registration, alteration registration or cancellation registration of employers to the SMIB according to the provisions.
Article 5 The payment base for an in-service employee shall be his average monthly wage in the previous year. If his average monthly wage in the previous year exceeds 300% of average monthly wage of all the in-service employees in this Municipality in the previous year, the amount exceeding 300% shall not be included in his payment base; and if his average monthly wage in the previous year is less than 60% of average monthly wage of all the in-service employees in this Municipality in the previous year, his payment base shall be the 60% of average monthly wage of all the in-service employees in this Municipality in the previous year.
An in-service employee shall pay basic medical insurance premiums at 2% of his payment base. A retiree himself needs not to pay basic medical insurance premiums.
Article 6 The payment base of an employer shall be the sum of all the payment bases of its employees.
An employer shall pay basic medical insurance premiums at 10% of its payment base, and pay local additional medical insurance premiums at 2% of its payment base.
Article 7 Costs and expenses of medical insurance premiums paid by employers shall be listed according to the channels designated by the treasury department.
Article 8 The calculation of insurance premiums paid by an employer and his in-service employees, the procedures for payment and the handling of disputes over collection and payment of insurance premiums shall be governed by the provisions on the administration of the collection and payment of social insurance premiums.
Chapter III Individual Medical Accounts, Pooling Funds and Additional Funds
Article 9 Basic medical insurance funds consist of the pooling fund and the individual medical accounts.
Basic medical insurance premiums paid by an employer shall be incorporated into pooling fund except the amount to be incorporated into his individual medical account according to Article 11 of these Measures.
Article 10 After an employer has gone through the registration formality for basic medical insurance and has paid medical insurance premiums, the SMIAC shall establish individual medical accounts for its employees.
Article 11 Basic medical insurance premiums paid by an in-service employee shall be totally incorporated into his individual medical account.
About 30% of basic medical insurance premiums paid by an employer shall be incorporated into individual medical accounts.
The ratios for incorporation of basic medical insurance premiums paid by an employer for its employees into individual medical accounts shall be different based on the age spans of employees.
The age spans of in-service employees shall be divided into:
1. under 34 years old;
2. 35-44 years old; and
3. over 45 years old.
The age spans of retirees shall be divided into:
1. from the date of retirement but under 74 years old; and
2. over 75 years old.
The specific ratios for incorporation of basic medical insurance premiums paid by an employer for its employees into individual medical accounts as well as the adjustment of these ratios shall be studied and demonstrated by the SMIB jointly with other relevant departments and be promulgated and implemented after being reported to the Municipal People's Government for approval.
Article 12 If an employer fails to pay basic medical insurance premiums when it ought to do so or is suspended from enjoying the treatment of basic old-age insurance treatment, the incorporation of premiums shall be ceased according to Article 11 of these Measures.
Article 13 The capital in an individual medical account shall be owned by the individual himself, and can be carried forward to another year and be inherited.
The capital in an individual medical account shall include the capital incorporated in the current year and the surplus capital from previous years.
The interest on year-end capital in an individual medical account shall be calculated according to relevant provisions, and be incorporated into the individual medical account.
Article 14 An employer can inquire about the incorporation and expenditure of the capital in his individual medical account, and the SMIB, SMIB branch offices and the SMIAC shall provide convenience for employees to make inquiry.
Article 15 The local additional medical insurance premiums paid by an employer shall be totally incorporated into the local additional medical insurance fund (hereinafter referred to as the “additional fund”).
Chapter IV Hospitalization of Employees and Provision of Medical Services
Article 16 The “designated medical institutions” as mentioned in these Measures refers to the medical institutions which have obtained practicing licenses upon approval of the health administrative department and upon examination and approval of the SMIB and are approved to establish the settlement relationship of basic medical insurance.
The “designated retail drug stores” as mentioned in these Measures refers to the drug retail enterprises which have obtained business qualifications upon approval of the drug supervisory and administrative department and upon examination and approval of the SMIB and are approved to establish the settlement relationship of basic medical insurance.
Article 17 Designated medical institutions and designated retail drug stores shall provide services for employees, and apply for settlement of medical expenses according to the diagnosis and treatment items, medical service facilities, medicines and payment rates for basic medical insurance.
Article 18 The provisions on diagnosis and treatment items, medical service facilities, medicines and payment rates for basic medical insurance shall be formulated by the SMIB jointly with other relevant departments according to the provisions of the state.
Article 19 Employees can get medical treatment at the designated medical institutions in this Municipality.
Employees can prepare medicines at designated medical institutions or designated retail drug stores according to the provisions.
If the place of employment or the place of residence of an employee is located in another province or city, or he gets emergency treatment in another province or city, he can get medical treatment at the local medical institutions.
Article 20 When an employee gets medical treatment at a designated medical institution or prepares medicines at a designated retail drug store in this Municipality, he shall show his medical insurance voucher.
The designated medical institution or the designated retail drug store shall check medical insurance vouchers of employees.
No individual may use under false pretenses, forge, alter or lend his medical insurance vouchers.
Chapter V Payment of Medical Expenses
Article 21 If an employer and its employees have paid medical insurance premiums according to the provisions, its employees can enjoy the treatment of basic medical insurance from the following month after payment of medical insurance premiums; otherwise, its employees can not enjoy the treatment of basic medical insurance.
If an employer applies for deferred payment of medical insurance premiums according to relevant provisions, its employees shall continuously enjoy the treatment of basic medical insurance within the period of deferral as approved.
If an employer or any of its employees fails to pay medical insurance premiums, that employee can not enjoy the treatment of basic medical insurance until enough medical insurance premiums have been made up.
If an employer and any of its employees have paid medical insurance premiums for 15 years or more (including the years in which medical insurance premiums shall be regarded as having been paid), that employee can enjoy the treatment of basic medical insurance after his retirement. The calculation of the years in which medical insurance premiums shall be regarded as having been paid shall be separately provided by the SMIB.
If an employee has reached the statutory age of retirement and has gone through the retirement formality, the part of basic medical insurance premiums to be paid by his employer and to be incorporated into his individual medical account shall be calculated according to the ratio for his last in-serve month; and the payment of medical expenses shall be governed by the provisions on the basic medical insurance for retirees.
The retirees who have enjoyed the treatment of basic medical insurance according to relevant provisions before promulgation of these Measures shall not be restricted by the provisions in this Article.
Article 22 The expenses other than those provided by Articles 24 and 25 of these Measures an in-service employee has paid within one year for outpatient and emergency medical treatment or preparation of medicines at designated retail drug stores shall be paid by the capital in his individual medical account. The insufficient part shall be paid by the employee himself to the self-payment amount for outpatient and emergency medical treatment, and the surplus part shall be paid according to the following provisions (excluding the expenses paid for preparation of medicines at designated retail drug stores)
1. If the employee was borne before December 31, 1955 and started work before December 31, 2000, the self-payment amount for outpatient and emergency medical treatment shall be 1,500 yuan, 70% of surplus medical expenses shall be paid by additional fund, and the remaining part shall be borne by the employee himself;
2. If the employee was borne after January 1, 1956 but before December 31, 1965 and started work before December 31, 2000, the self-payment amount for outpatient and emergency medical treatment shall be 1,500 yuan, 60% of surplus medical expenses shall be paid by additional fund, and the remaining part shall be borne by the employee himself;
3. If the employee was borne after January 1, 1966 and started work before December 31, 2000, the self-payment amount for outpatient and emergency medical treatment shall be 1,500 yuan, 50% of surplus medical expenses shall be paid by additional fund, and the remaining part shall be borne by the employee himself; and
4. If the employee newly started work after January 1, 2001, the self-payment amount for outpatient and emergency medical treatment shall be 1,500 yuan, 50% of surplus medical expenses shall be paid by additional fund, and the remaining part shall be borne by the employee himself.
Article 23 The expenses other than those provided by Articles 24 and 26 of these Measures a retiree has paid within one year for outpatient and emergency medical treatment or preparation of medicines at designated retail drug stores shall be paid by the capital in his individual medical account. The insufficient part shall be paid by the retiree himself to the self-payment amount for outpatient and emergency medical treatment, and the surplus part shall be paid according to the following provisions (excluding the expenses paid for preparation of medicines at designated retail drug stores):
1. If the retiree went through the retirement formality before December 31, 2000, the self-payment amount for outpatient and emergency medical treatment shall be 300 yuan; if he gets outpatient and emergency medical treatment at Class A medical institutions, 90% of surplus medical expenses shall be paid by additional fund; if he gets outpatient and emergency medical treatment at Class B medical institutions, 85% of surplus medical expenses shall be paid by additional fund; and if he gets outpatient and emergency medical treatment at Class C medical institutions, 80% of surplus medical expenses shall be paid by additional fund; and the remaining part shall be borne by the retiree himself;
2. If the retiree was borne before December 31, 1955, started work before December 31, 2000, and went through the retirement formality after January 1, 2001, the self-payment amount for outpatient and emergency medical treatment shall be 700 yuan; if he gets outpatient and emergency medical treatment at Class A medical institutions, 85% of surplus medical expenses shall be paid by additional fund; if he gets outpatient and emergency medical treatment at Class B medical institutions, 80% of surplus medical expenses shall be paid by additional fund; and if he gets outpatient and emergency medical treatment at Class C medical institutions, 75% of surplus medical expenses shall be paid by additional fund; and the remaining part shall be borne by the retiree himself;
3. If the retiree was borne after January 1, 1956 but before December 31, 1965, started work before December 31, 2000, and went through the retirement formality after January 1, 2001, the self-payment amount for outpatient and emergency medical treatment shall be 700 yuan; if he gets outpatient and emergency medical treatment at Class A medical institutions, 70% of surplus medical expenses shall be paid by additional fund; if he gets outpatient and emergency medical treatment at Class B medical institutions, 65% of surplus medical expenses shall be paid by additional fund; and if he gets outpatient and emergency medical treatment at Class C medical institutions, 60% of surplus medical expenses shall be paid by additional fund; and the remaining part shall be borne by the retiree himself;
4. If the retiree was borne after January 1, 1966, started work before December 31, 2000, and went through the retirement formality after January 1, 2001, the self-payment amount for outpatient and emergency medical treatment shall be 700 yuan; if he gets outpatient and emergency medical treatment at Class A medical institutions, 55% of surplus medical expenses shall be paid by additional fund; if he gets outpatient and emergency medical treatment at Class B medical institutions, 50% of surplus medical expenses shall be paid by additional fund; and if he gets outpatient and emergency medical treatment at Class C medical institutions, 45% of surplus medical expenses shall be paid by additional fund; and the remaining part shall be borne by the retiree himself; and
5. If the retiree started work and went through the retirement formality after January 1, 2001, the self-payment amount for outpatient and emergency medical treatment shall be 700 yuan; if he gets outpatient and emergency medical treatment at Class A medical institutions, 55% of surplus medical expenses shall be paid by additional fund; if he gets outpatient and emergency medical treatment at Class B medical institutions, 50% of surplus medical expenses shall be paid by additional fund; and if he gets outpatient and emergency medical treatment at Class C medical institutions, 45% of surplus medical expenses shall be paid by additional fund; and the remaining part shall be borne by the retiree himself.
Article 24 Where an employee gets severe uremia dialysis, cancer chemotherapy or radiotherapy (hereinafter referred to as “outpatient medical treatment against serious illness”), if he is an in-service employee, 85% of medical expenses shall be paid by pooling fund; if he is a retiree, 92% of medical expenses shall be paid by pooling fund. The remaining part shall be paid by the surplus capital in his individual medical account from previous years, and the insufficient part shall be borne by the employee himself.
For the medical expenses for the home sickbed of an employee, 80% thereof shall be paid by pooling fund, the remaining part shall be paid by the surplus capital in his individual medical account from previous years, and the insufficient part shall be borne by the employee himself.
Article 25 There shall be a minimum amount of medical expenses to be paid by pooling fund for an in-service employee's hospitalization or stay in emergency office for observation. The minimum amount shall be 1,500 yuan.
For the medical expenses paid by an in-service employee for his hospitalization or stay in emergency office for observation within one year, if the accumulated amount thereof has exceeded the minimum amount, 85% of thereof shall be paid by pooling fund.
The medical expenses paid by an in-service employee below the minimum amount as well as the remaining medical expenses after the payment by the pooling fund shall be paid by the surplus capital in his individual medical account from previous years, and the insufficient part shall be borne by the employee himself.
Article 26 There shall be a minimum amount of medical expenses to be paid by pooling fund for a retiree's hospitalization or stay in emergency office for observation. The minimum amount shall be 700 yuan if he retired before December 31, 2000; and the minimum amount shall be 1,200 yuan if he retired after January 1, 2001.
For the medical expenses paid by a retiree for his hospitalization or stay in emergency office for observation within one year, if the accumulated amount thereof has exceeded the minimum part, 92% thereof shall be paid by pooling fund.
The medical expenses paid by a retiree below the minimum amount as well as the remaining medical expenses after the payment by the pooling fund shall be paid by the surplus capital in his individual medical account from previous years, and the insufficient part shall be borne by the retiree himself.
Article 27 The maximum amount of medical expenses to be paid by pooling fund shall be 70,000 yuan. If the sum of the medical expenses exceeding the minimum amount as paid by an employee for his hospitalization or stay in emergency office for observation and the medical expenses for the outpatient medical treatment against serious illness or the home sickbed are below the maximum amount, the abovementioned medical expenses shall be paid by pooling fund according to the payment ratios provided by Articles 24, 25 and 26 of these Measures.
For the medical expenses above the maximum amount to be paid by pooling fund, 80% thereof shall be paid by additional fund, and the remaining part thereof shall be borne by the employee himself.
Article 28 All the medical expenses for outpatient and emergency medical treatment, hospitalization and stay in emergency office for observation because an employee suffers from Class A infectious disease, gets a family planning operation or suffers sequela from family planning operation, if they are in consistency with the provisions on basic medical insurance, shall be totally paid by the pooling fund.
For the medical expenses for hospitalization or stay in emergency office for observation because an employee suffers from a work-related injury or occupational disease, if they exceed the minimum amount to be paid by pooling fund, 50% of surplus expenses shall be paid by pooling fund, and the remaining part and relevant medical expenses for outpatient and emergency medical treatment shall be paid by his employer according to the relevant provisions of the state and this Municipality.
Article 29 Under any of the following circumstances, no medical expenses may be paid by pooling fund, additional fund or the capital in individual medical account:
1. Medical expenses paid by an employee for his medical treatment or preparation of medicines at a non-designated medical institution or preparation of medicines at a non-designated retail drug store;
2. Medical expenses paid by an employee for his hospitalization or preparation of medicines in excess of the scope of diagnosis and treatment items, medical service facilities, medicines or payment rates for basic medical insurance;
3. Medical expenses paid by an employee for suicide, self-injury, fight, drug taking, medical accident or traffic accident, etc.; or
4. Any other circumstances provided by the provisions of the state and this Municipality.
Chapter VI Settlement of Medical Expenses
Article 30 The medical expenses, which are paid by an employee for medical treatment or preparation of medicines and comply with the provisions on basic medical insurance, shall be dealt with upon the strength of medical insurance vouchers of employees according to the following provisions:
1. If the abovementioned medical expenses should be paid by pooling fund or additional fund, the designated medical institution shall create accounts according to facts; and
2. If the abovementioned medical expenses should be paid by the capital in the individual medical account, the designated medical institution or the designated retail drug store shall deduct them from the individual medical account of the employee, and shall collect them from the employee if the capital in the individual medical account is not enough.
For the medical expenses that are paid by an employee for medical treatment or preparation of medicines but do not comply with the provisions on basic medical insurance, the designated medical institution or the designated retail drug store shall collect them from the employee.
Article 31 Designated medical institutions and designated retail drug stores shall settle the medical expenses deducted from the individual medical accounts of employees at the designated SMIB branch offices every month.
For the book-entry medical expenses that should be paid by pooling fund and additional fund, designated medical institutions shall settle them at the designated SMIB branch offices every month.
For the medical expenses that can be paid by pooling fund, additional fund or the capital in individual medical account according to Paragraph 3 of Article 19 of these Measures, employees can settle them at the designated SMIB branch offices upon the strength of their medical insurance vouchers.
Article 32 For the medical expenses applied for settlement, a SMIB branch office shall make preliminary examination within ten workdays after receipt of the application for settlement, and report its preliminary examination opinions to the SMIB.
The SMIB shall, within ten workdays after receipt of preliminary examination opinions of a SMIB branch office, make a decision of approving, deferring or rejecting the payment. After the SMIB has made a decision of deferring the payment, it shall make a decision of approving or rejecting the payment within 90 days and notify the result to the relevant entity.
For the medical expenses that are approved by the SMIB, the SMIAC shall, within seven workdays after the date of approval, allot the capital from the medical insurance fund; and for the medical expenses that are rejected by the SMIB, they shall be borne by the designated medical institution, the designated retail drug store or the employee himself.
Article 33 The SMIB can settle medical expenses with designated medical institutions by ways of total prepaid settlement, settlement by service items and settlement by service units, etc.; and the medical expenses exceeding settlement standards shall be shared by the medical insurance fund and the designated medical institution according to the provisions.
Article 34 No designated medical institution, designated retail drug store or individual may settle medical expenses by forging or altering accounts, materials, outpatient prescriptions, emergency prescriptions, bills of medical expenses, or resorting to any other unjustifiable means.
Article 35 The SMIB and the SMIB branch offices shall supervise and inspect the settlement of medical expenses by designated medical institutions, designated retail drug stores and individuals, and the entities and individuals subject to inspection shall faithfully provide records, prescriptions, medical history and other materials in connection with the settlement of medical expenses.
If the frequency of outpatient and emergency medical treatment of an individual or the expenses occurred significantly exceed the normal level, the SMIB can adopt the measure of changing the settlement method against him.
Chapter VII Legal Liabilities
Article 36 If a designated medical institution or designated retail drug store violates Article 17, Paragraph 2 of Article 20, Article 30 or Article 34 of these Measures or other provisions on medical insurance, and which makes the medical insurance fund suffer from losses, the SMIB shall order it to make correction within a time limit, recover the relevant medical expenses as paid, and can give it a warning or a fine of more than 3,000 yuan but less than 100,000 yuan; if the circumstances are serious, the SMIB can suspend the settlement relationship of basic medical insurance with the violator and cancel its designated qualification.
If any relevant offices or staff members of a designated medical institution or designated retail drug store seriously violate the provisions on medical insurance, the SMIB can adopt the measure of suspending the settlement and payment of medical insurance compensations.
Article 37 If an individual violates Paragraph 3 of Article 20 or Article 34 of these Measures or other provisions on medical insurance, and which causes the medical insurance fund suffer from losses, the SMIB shall order him to make correction, recover the relevant medical expenses as paid, and can give him a warning or a fine of more than 100 yuan but less than 10,000 yuan.
Article 38 If any functionary in the administrative department of medical insurance or the SMIB misuses authorities, practices favoritism or neglects duties, and which causes the medical insurance fund suffer from losses, the SMIB shall recover the medical insurance fund as lost; and if a crime is constituted, criminal liabilities shall be imposed on the criminal; and if there is no crime, administrative sanctions shall be imposed on the violator.
Chapter VIII Supplementary Provisions
Article 39 The administration and supervision of pooling fund and additional fund shall be governed by the relevant provisions of the state and this Municipality on the social insurance fund. The pooling fund and the additional fund shall be incorporated into the special treasury account of social security fund, be subject to uniform management, be entered into separate accounts, and be earmarked; and shall be subject to the supervision by the social insurance fund supervision organization established by the Municipal People's Government as well as the departments of treasury and audit.
The annual budget and final accounts of pooling fund and additional fund shall be made by the SMIB jointly with the Shanghai Financial Bureau according to legal provisions, and be implemented after having been reported to the Municipal People's Government for approval.
Article 40 Concrete measures for the basic medical insurance of urban individual economic organization owners, their staff members as well as free-lance professionals in this Municipality shall be separately formulated.
The basic medical insurance for the unemployed while they are obtaining the unemployment insurance compensations shall be governed by the relevant provisions of the state and this Municipality.
Article 41 For the employees who have reached the statutory age for retirement but temporarily do not go through the retirement formality and extend the length of work according to the provisions of the state, the provisions on the basic medical insurance for in-service employees shall be implemented; and after they have gone through the retirement formality, their basic medical insurance shall be governed by the relevant provisions on the retirees under the same age span.
Article 42 One year from the implementation of these Measures shall be the transitional period for this Municipality to practice the socialized management of basic medical insurance, and the concrete operational measures for the transitional period shall be separately formulated.
Article 43 The self-payment amount of outpatient and emergency medical treatment, the minimum amount to be paid by pooling fund as well as the maximum amount to be paid by pooling fund shall be adjusted at real time based on actualities. The concrete scheme of adjustment shall be studied by the SMIB jointly with other relevant departments and then be reported to the Municipal People's Government, and shall be promulgated and implemented upon approval of the Municipal People's Government.
Article 44 These Measures shall come into force as of December 1, 2000. If any relevant provisions promulgated by the Municipal People's Government hereinbefore are conflicting with these Measures, the latter shall prevail.