Measures
on Medical Insurance of Employees of Cities and Towns in the
Shenzhen Municipality
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(Adopted
at the 84th permanent meeting of the third municipal government,
promulgated and goes into
effect on July 1, 2003)
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Chapter one
General Principles
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Article
1
In order to establish and strengthen the medical protection
system of the Shenzhen municipality,
and protect the basic
medial rights and interests of employees, these measures are
formulated according
to relevant national laws and regulations
and combining with the actual situations of the city.
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Article
2
The social medical insurance system of employees of cities and
towns is carried out in the city.
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The
government establishes medical insurance system, such as basic
medical insurance, local supplementary
medial insurance and
birth medial insurance.
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The
government provides medical subsidies for civil servants,
encourages and supports enterprises
to establish supplementary
medical insurance system.
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Article
3
All employing units and employees in the city shall
participate in the basic medical insurance, local supplementary
medical insurance and birth medical insurance according to the
provisions of these measures.
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Employing
units mentioned in these measures refer to all organs, public
institutions, societies,
enterprises, non-enterprise unit
established by civilians and intermediary organs in the
administrative
area of the city.
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Employees
mentioned in these measures refer to person in-service
affiliated with the employing unit,
retiree described in these
measures, and unemployed person with residence registration of
the municipality
and is in the period of receiving unemployment
pension.
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Insured
unit mentioned in these measures refers to the employing unit
having participated in social
medical insurance.
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Insured
person mentioned in these measures refers to employee having
participated in social medical
insurance.
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Article
4
The system of social medical insurance shall comply with
the principles of combing fairness and efficiency, adjusting
rights with obligations, and adjusting the level of protection
with the level of the development
of productivity.
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Article
5
The basic medical insurance shall carry out the fund
management mode of combing overall social planning with personal
account.
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The
local supplementary medical insurance and birth medical
insurance shall be planned by overall
society.
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The
fund of basic medical insurance, local supplementary medical
insurance and birth medical insurance
shall be contained in
special financial account for social protection. Their income
and outlay
shall be administered by two separate ways. The fund
shall be used exclusively for medical insurance and shall not
be
seized or embezzled.
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When
the fund of basic medical insurance, local supplementary medical
insurance and birth medical
insurance are not sufficient because
of particular situations, such as illness explosion and prevail,
and serious natural disaster, the municipal finance shall
subsidize.
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Article
6 The
basic medical insurance has two kinds of forms: comprehensive
medical insurance and in-hospital
medical insurance.
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The
following people shall participate in the comprehensive medical
insurance:
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1.
person in-service with residence registration of the
municipality (including blue-stamped residence
registration, the
same hereinafter);
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2.
retiree, which has residence registration of the municipality
before retirement, and enjoys old-age
insurance paid monthly by
the municipal organization of social insurance;
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3. retiree, which has
residence registration of the municipality before retirement,
participates
the original trade overall plan of old-age
insurance and enjoys old-age pension paid monthly by the social
insurance organization of the Guangdong Province; |
4. other person in-service
described by the municipal government. |
The
following people shall participate in the in-hospital medical
insurance:
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1.
person in-service without residence registration of the
municipality;
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2.
retiree, which has no residence registration of the municipality
and enjoys old-age pension paid
monthly by the municipal
organization of social insurance;
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3.
unemployed person, which has residence registration of the
municipality and in the period of
receiving unemployment
pension.
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The
person in-service without residence registration of the
municipality may participate in the
comprehensive medical
insurance after the employing unit applies.
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Article
7
Anyone, who participates in the comprehensive medical
insurance or in-hospital medical insurance, shall participate
in
the local supplementary medical insurance at the same time.
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The
person in-service with residence registration shall participate
in the birth medical insurance
at the same time.
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Article
8
The municipal administrative organization of social
insurance (hereinafter referred to as the municipal organization
of social insurance), established by the people' s government
of the Shenzhen municipality (hereinafter
referred to as the
municipal government), takes the expense of medical insurance
work of the municipality.
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The
relevant departments of sanitation, medicine, price, planning
and finance shall assist the municipal
organization of social
insurance to accomplish the work of medical insurance.
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Chapter 2
Collection of Medical Insurance Premium
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Article
9
The fund of basic medical insurance comes from the basic medical
insurance premium and its interests,
financial subsidies and
other revenues.
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The
fund of local supplementary medical insurance comes from the
local supplementary medical insurance
premium and its interests
and other revenues.
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The
fund of birth medical insurance comes from the birth medical
insurance premium and its interests
and other revenues.
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Article
10
The paying base of the basic medical insurance premium,
local supplementary medical insurance premium and birth medical
insurance premium shall be established according to the
following provisions:
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1.
person in-service participating the comprehensive medical
insurance shall use the total amount
of his monthly wage as the
paying base. If the total amount of his monthly wage exceeds
300% of
the monthly average wage of the employees of cities and
towns in the last year, the 300% of the monthly average
wage of
the employees of cities and towns in the last year shall be used
as the paying base; if
the total amount of his monthly wage is
below 60% of the monthly average wage of the employees of cities
and towns in the last year, the 60% of the monthly average wage
of the employees of cities and towns in
the last year shall be
used as the paying base;
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2.
anyone, who participates the in-hospital medical insurance,
shall use the monthly average wage
of the employees of cities
and towns in the last year as the paying base;
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3.
retiree described in item 2, paragraph 2 of article 6 shall use
his monthly basic retirement
pension as the paying base;
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4.
retiree described in item 3, paragraph 2 of article 6 shall use
the monthly average wage of the
employees of cities and towns in
the last year before his retirement as the paying base;
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5.
the paying base of local supplementary medical insurance premium
and birth medical insurance
premium shall be established
according to the paying base of basic medical insurance premium.
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Article
11
The employing unit and employee shall pay the basic
medical insurance premium, local supplementary medical insurance
premium and birth medical insurance premium according to the
following standards:
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1.
As to the comprehensive medical insurance premium, employee
in-service shall pay 2% of the paying
base, the employing unit
shall pay 6%; in regard to the retiree, described in item 2,
paragraph
2 of article 6, the municipal organization of social
insurance shall pay 11.5% of the paying base, which shall be
paid out from the common fund of the basic old-age insurance; in
regard to the retiree, described
in item 3, paragraph 2 of
article 6, the original employing unit shall pay off for only
one time,
according to the amount of 11.5% (of the paying
base)*12(month)*18(year).
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2.
As to the in-hospital medical insurance premium, in regard to
employee in-service described in
item 1, paragraph 3 of article
6, the employing unit shall pay according to 0.8% of the paying
base; in regard to person described in item 2 or 3, paragraph 3
of article 6, the municipal organization of social
insurance
shall pay according to 0.8% of the paying base, which shall be
paid out from the common
fund of the basic old-age insurance and
the fund of unemployment insurance;
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3.
As to the local supplementary medical insurance premium, in
regard to those who participate the
comprehensive medical
insurance, they shall pay according to 0.5% of the paying base;
in regard
to those who participate the in-hospital medical
insurance, they shall pay according to 0.2% of the paying base.
Except that the employing unit shall pay for person in-service,
the paying channel and manner of
others shall be carried out
according to the provisions of the two preceding items;
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4.
The birth medical insurance premium shall be paid by the
employing unit according to 0.5% of
the paying base.
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Article
12
The basic medical insurance premium, local supplementary
medical insurance premium and birth medical insurance premium,
shall be transferred into the account of the fund of social
insurance, which is opened by the municipal
organization of
social insurance in the bank, after being collected by the
deposit bank.
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Article
13
The social medical insurance premium paid by the insured
unit and person shall be managed uniformly by the municipal
organization of social insurance through establishing overall
fund of medical insurance and individual
account separately. The
specific measures are:
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1.
As to the comprehensive medical insurance premium, the part paid
by individual shall all be counted
into individual accounts; as
regard to the part paid by the employing unit or by the
municipal
organization of social insurance, if the insured
person in-service is younger than 35 (not including as old as
35), 30% of the amount shall be counted into individual account;
if he is younger than 45 but older
than 35 (not including as old
as 45), 40% of the amount shall be counted into individual
accounts;
if he is older than 45, 50% of the amount shall be
counted into individual accounts.
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As
regard to retiree described in item 2, paragraph 2 of article 6,
60% of the amount shall be counted
into individual account; as
to retiree described in item 3, paragraph 2 of article 6, the
amount
that shall be counted into individual account is 11.5% *
60% * the monthly average salary of employees of cities
and
towns in the last year; the other part shall be counted into the
overall fund of basic medical
insurance;
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2.
The in-hospital medical insurance premium shall all be
counted in the overall fund of basic medical insurance; the
individual account shall not be established.
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3.
The local supplementary medical insurance premium shall
all be counted in the fund of local supplementary medical
insurance; the individual account shall not be established, and
shall only be used to pay the treatment
of local supplementary
medical insurance;
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4.
The birth medical insurance premium shall all be counted in the
fund of birth medical insurance;
the individual account shall
not be established, and shall only be used to pay the medical
expense
of birth medical insurance.
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Article
14
The employing unit shall register and participate
insurance within 30 days after the establishment or receiving
the business license.
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Article
15
The medical insurance premium may be paid consecutively
by the insured person with the residence registration of
the
municipality, if he participates in the basic medical insurance
for more than 1 consecutive
year, and there is no employing unit
to pay the medical insurance premium for him because he changes
his job. It shall be considered as consecutive paying, but the
longest period of consecutive paying shall
not exceed 3 months.
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Article
16
The medical insurance premium paid by enterprise shall be
listed in cost, the premium paid by organs, public institution
and unit shall be expended from the fund of administrative
affairs; the premium ought to be paid
by individual shall be
paid before tax.
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Article
17
The interests of the fund of social medical insurance and
individual account of the insured person shall be calculated
according to relevant national provisions.
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Article
18 The municipal government may adjust the standard of the basic
medical insurance premium, local supplementary insurance
premium
and birth medical insurance premium, which shall be paid by
employing unit and individual,
according to the specific
situation of the economic development, the growing of
employee' s salary,
the level of price and the expenditure of
medical premium. |
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Chapter 3
Treatment of Medical Insurance
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Article
19
The insured person begins to enjoy the treatment of
medical insurance stipulated in these measures from the first
day of the next month upon transacting the formalities of
participating insurance.
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If
the insured person or his unit stops to pay the medical
insurance premium, he stops to enjoy
the treatment of medical
insurance from the first day of the next month upon stopping
payment,
with the exception of individual account.
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Article
20
The insured person of basic medical insurance enjoys the medical
treatment in the range of medicine
catalog of basic medical
insurance, items of diagnosis and treat, and standards for
facilities
of medical service, and other medical treatment
stipulated.
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The
insured person of local supplementary insurance enjoys the
treatment of local supplementary
medical insurance stipulated in
these measures.
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The
insured person of birth medical insurance enjoys the treatment
of birth medical insurance stipulated
by these measures.
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Article
21
The medicine catalog and items of diagnosis and treat of
medical insurance shall comply with the system of access.
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The
medicine catalog of basic medical insurance shall accord with
the catalog promulgated by the
administrative department of
social insurance of the Guangdong Province and of the country;
the
items of diagnosis and treat of basic medical insurance, the
standards for facilities of basic medical service and
the
medicine catalog of local supplementary medical insurance and
the range of items of diagnosis
and treat shall be laid down by
the municipal organization of social insurance and be
promulgated. |
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Article
22
As to person in-service participating the comprehensive
medical insurance, 90% of his basic medical expense in hospital
shall be paid from the overall fund of basic medical insurance,
the other 10% shall be paid by
themselves; as to retiree
participating the comprehensive medical insurance, 95% of his
basic medical
expense in hospital shall be paid from the overall
fund of basic medical insurance, the other 5% shall be paid by
himself, except that these measures stipulated otherwise.
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Article
23
The basic medical expense of outpatient service, the
expense of the items of diagnosis and treat, the medicine in
medicine catalog of the local supplementary medical insurance
used in outpatient service of insured
person of the
comprehensive medical insurance, shall be paid from the
individual account; if the
individual account can not pay it
off, 70% of the basic medical expense of outpatient service,
which exceeds 10% of the yearly average salary of municipal
employees of cities and towns last year, in the year
of medical
insurance, shall be paid from the overall fund of basic medical
insurance, the other
30% shall be paid by himself.
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Article
24
As to the basic medical expense of insured person of
in-hospital medical insurance in hospital, 90% shall be paid
from the overall fund of basic medical insurance, 10% shall be
paid by himself. If the insured
person is a retiree, 95% of his
basic medical expense in hospital shall be paid from the overall
fund of basic medical insurance, 5% shall be paid by himself,
with the exception that these measures stipulated
otherwise.
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Other
medical expense of outpatient service, which is not stipulated
in article 27 of insured person
of in-hospital medical
insurance, shall be paid by himself.
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Article
25 When the insured person of the comprehensive medical
insurance goes to outpatient service, 80% of the expense
occurred in the check by large medical equipment and curing
because of the situation of his illness
shall be paid from the
overall fund of basic medical insurance, the other 20% shall be
paid by
himself, after being examined and approved by the
municipal organization of social insurance or medical
organization authorized by it. |
The check item by large
medical equipment and curing item shall be established by the
municipal
organization of social insurance. |
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Article
26
In case that the insured person use special material for
medical use or use material for medical use only one time
with a
unit price of above 1000, or install or replace man-made
apparatus during the treatment
in the items of diagnosis and
treat of basic medical insurance, after being examined and
approved
by the municipal organization of social insurance, the
overall fund of basic medical insurance shall pay 90% of
the
expense occurred according to the price of home-made style of
widespread; or pay 50% of the
expense occurred according to the
price of import style of widespread if there is no comparable
price of home-made style.
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The
range of special material for medical use and man-made apparatus
shall be established by the
municipal organization of social
insurance.
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Article
27
In case that the insured person use dialysis of chronic
prostration of nephric function for out-patient, anti-rejection
medicine for out-patient after organ transplantation, malignancy
chemotherapy for out-patient,
intervention therapy, radiotherapy
therapy or nuclide therapy, after being examined and approved by
the municipal organization of social insurance, 90% of his basic
medical expense occurred shall be paid from
the overall fund of
basic medical insurance, the other 10% shall be paid by himself.
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The
range of organ transplantation shall be established by the
municipal social insurance.
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Article
28 The highest amount of money, paid from the overall fund of
basic medical insurance by insured person in every medical
insurance year, shall not exceed 4 times of yearly average
salary of the city-and-town employees
in last year, and shall be
linked up with his time of participating insurance
consecutively. The
specific standards are: |
1.
if the time of participating insurance consecutively is
shorter than half a year, the highest amount of money paid
from
the overall fund of basic medical insurance is 0.5 times of
yearly average salary of the city-and-town
employees in last
year; |
2. if the time of
participating insurance consecutively is shorter than a year,
the highest amount
of money paid from the overall fund of basic
medical insurance is 1 times of yearly average salary of the
city-and-town employees in last year; |
3.
if the time of participating insurance consecutively is longer
than a year but shorter than two
years, the highest amount of
money, paid from the overall fund of basic medical insurance is
2
times of yearly average salary of the city-and-town employees
in last year;
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4.
if the time of
participating insurance consecutively is longer than two years
but shorter than three
years, the highest amount of money paid
from the overall fund of basic medical insurance is 3 times of
yearly average salary of the city-and-town employees in last
year;
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5.
if the time of
participating insurance consecutively is longer than three
years, the highest amount
of money paid from the overall fund of
basic medical insurance is 4 times of yearly average salary of
the city-and-town employees in last year;
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Article
29
As to the insured person of the local supplementary
medical insurance, 85% of the following expenses shall be paid
from the fund of the local supplementary medical insurance, the
other 15% shall be paid by himself:
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1.
the basic medical expense exceeding the highest amount of
money paid from the overall fund of basic medical insurance; |
2. the expense occurred in
hospital of medicine described in the medicine catalog of local
supplementary
medical insurance, or items for diagnosis and
treat of local supplementary medical insurance. |
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Article
30
The highest quota of medical expense, paid from the fund
of the local supplementary medical insurance in each medical
insurance year of the insured person of the local supplementary
medical insurance, shall be linked
with the time of
participating basic medical insurance consecutively. The
specific standards are:
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1.
If the time of participating insurance consecutively is longer
than half a year but shorter than
1 year, the highest quota of
medical expense paid from the fund of local supplementary
medical
insurance is 50,000 yuan;
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2.
If the time of participating insurance consecutively is longer
than a year but shorter than 2
years, the highest quota of
medical expense paid from the fund of local supplementary
medical insurance
is 100,000 yuan;
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3.
If the time of participating insurance consecutively is longer
than 2 years but shorter than
3 years, the highest quota of
medical expense paid from the fund of local supplementary
medical
insurance is 150,000 yuan;
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4.
If the time of participating insurance consecutively is longer
than 3 years, the highest quota
of medical expense paid from the
fund of local supplementary medical insurance is 200,000 yuan;
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Article
31
The basic medical expense of perinatal check, parturition
hospitalization, visit and check after
parturition and operation
of family planning of the insured person of birth medical
insurance shall
be paid from the fund of birth medical
insurance. |
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Article
32
In case that the insured person refuses to leave hospital
although meeting the requirement to leave, and being affirmed
by
the fixed medical organization, his medical expense occurred
after the day on which he is affirmed
to leave hospital shall
all be paid all by himself.
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The
insured person may apply to the municipal organization of social
insurance for appraisal within
3 working days upon the day he is
affirmed by the fixed medical organization to leave hospital, if
he has dispute with the fixed medical organization about leaving
hospital.
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The
committee of experts on medical insurance shall be consigned by
the municipal organization of
social insurance to appraise, and
shall make appraisal conclusion within 7 working days upon
reception
of the application. The date to leave hospital
affirmed by the appraisal decision made by the committee of
experts on medical insurance is the leaving day.
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Article
33 The
expense of medical service, beyond the range of basic medical
insurance, local supplementary
insurance and birth medical
insurance, shall be paid by the insured person himself.
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If
the accumulated money of the individual account reaches two
times of town employee' s average
monthly income of the
previous year of whole municipality, the excess part can be used
to pay the
basic medical expense, or local supplementary medical
expense paid by the individual when seeing a doctor in the
fixed
medical organization, or pay non-prescription medicine in the
medicine catalog of basic medical
insurance and the local
supplementary medical insurance. |
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Article
34
If the insured person is the counterpart of health care,
his medical expense in the scope of basic medical insurance
and
local supplementary medical insurance shall be paid as
stipulated by the municipal organization
of social insurance¡£
The excessive
part shall be settled by the municipal government according to
relevant provisions.
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Article
35
The medical expense of insured person due to industrial
injury or occupational disease shall be settled according
to
relevant provisions on insurance of industrial injury.
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Article
36
If the insured person leaves the municipality, the
remaining sum of his individual account shall be transferred
into the local organization of social insurance of his residence
registration; if there is no corresponding
organization, the
remaining sum shall be returned to him at one time.
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If
the insured person died, the remaining sum of his individual
account shall be paid to his inheritor
at one time; if there is
no inheritor, it shall be transferred to the overall fund of
basic medical
insurance.
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Article
37
If the insured person goes in hospital for emergency in
another domestic city (not including Hongkong, Macao and
Taiwan), during a business trip or visiting relatives, or is
allowed by the municipal organization
of social insurance to
transfer to another domestic city to be in hospital, the basic
medical expense
and local supplementary medical expense shall be
checked and reimbursed according to relevant provisions of these
measures.
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The
insured person with registered permanent residence in Shenzhen,
who works in other domestic
city for a long time or lives in
other domestic city after retirement, shall be recorded with the
municipal organization of social insurance. His basic medical
expense and local supplementary medical expense
occurred in
hospital at his working place or living place shall be examined
and reimbursed according
to relevant regulations. |
The
outpatient basic medical expense of the insured person occurred
in other domestic city may be
deducted from his individual
account. |
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Article
38
The insured person shall enjoy medical insurance
treatment according to the compensation standard of municipal
hospital if he gets in hospital under emergency during a
business trip, visiting relatives or in
Hongkong, Macao or
Taiwan.
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Article
39
The insured person can not enjoy the medical insurance
treatment stipulated in these measures under any one of the
following circumstances:
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1.
going to hospital in other domestic city or Hongkong, Macao,
Taiwan or abroad arbitrarily;
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2.
going to non-pointed medical organization for treatment in the
city arbitrarily, except that
his life is endangered and needs
to be rescued;
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3.
buying medicine arbitrarily, except that the circumstances
stipulated in paragraph 2 of article
33;
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4.
being injured because of traffic accident, medical accident or
other negligent accident;
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5.
being injured because of kill, wound or injure himself, drink
excessively, brawl or his own illegal
behavior;
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6. being injured because
of other people' s injurious act; |
7. other circumstances
stipulated by the country, province or city. |
Article
40
The insured people shall not enjoy the medical insurance
treatment stipulated in these measures if he uses the following
items for diagnosis and treat or material for medical use:
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1.
service of registration, consultation outside hospital or
special medical service;
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2.
non-illness treatment of face beauty, non-functional
face-lifting, physical examination, medical
consultation or
illness prevention;
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3.
non-basic medical insurance treatment of PET or photon knife;
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4.
material for medical use only one time;
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5.
recovery appliance, such as glasses, artificial tooth and
hearing-aid;
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6.
resources of organs or tissues for transplantation;
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7.
other transplantation of organs or tissues other than kidney,
bone marrow and cornea;
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8.
complementary treatment such as qigong and magnet therapy;
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9.
treatment of various barrenness and sterility or sexual
disorder;
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10.
various scientific or clinical treatment;
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11.
other treatment stipulated by relevant provisions of country,
province or city whose expense
shall not be reimbursed.
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The specific range of treatment and material for medical
use listed in the preceding paragraph shall be described
by the
municipal organization of social insurance, and adjusted
according to the needs of social
medial insurance and
development of medial skill.
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Chapter 4
Fixed Medical Organization and Fixed Retail Drugstore of
Medical Insurance
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Article
41
The social medical insurance system shall comply with the
administration of fixed medical organization and fixed
retail
drugstore.
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The
municipal organization of social insurance shall enact the
measures on the examination and approval
of qualification of the
fixed medical organization and fixed retail drugstore jointly
with the
administrative departments of sanitary and medicine.
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Article
42 The
municipal organization of social insurance shall establish the
fixed medical organization and
fixed retail drugstore according
to the principles of overall planning, reasonable arrangement,
convenience for seeing a doctor, giving attention to the needs
and encouraging competition.
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National
medical organization shall not refuse once being chosen by the
municipal organization of
social insurance to be a fixed medical
organization. Other fixed medical organization shall be
established by the municipal organization of social insurance
and medical organization through consultation.
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The
municipal organization of social insurance shall make agreement
with the fixed medical organization. |
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Article
43
The fixed medical organization shall insist the
principles of "curing on the basis of the sickness, reasonable
check, reasonable using the medicine and reasonable curing" ,
and provide good, efficient and cheap
medical service to the
insured person according to the provisions of these measures and
the agreement.
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Article
44
The fixed medical organization shall establish the system
to check and manage the therapy and medicine separately,
standardize the medical behaviors and lower the proportion of
the expense paid by the insured person
himself to the total
amount of the medical expense, and reduce the economic burden of
the insured
person.
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Article
45
The fixed medical organization and fixed retail drugstore
shall establish the interior administration system corresponding
to the medical insurance system.
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Article
46 The
fixed medical organization shall have medical service
facilities, which meet 80% of the requirements
on the standards
of the basic medical insurance service facilities; the fixed
medical organization
and fixed retail drugstore shall have more
than 80% of the medicine listed in the catalog of the basic
medical insurance and the local supplementary medical insurance. |
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Article
47 The
fixed medical organization and the fixed retail drugstore shall
implement strictly the provisions
of the government concerning
the standard of medical expense and the price of the medicine,
and
shall publicize them.
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The
fixed medical organization shall provide the detail list of
daily expense in the outpatient
service or being in hospital to
the insured person.
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Article
48 The
fixed medical organization shall implement relevant
administration provisions on the medicine
catalog, curing items
and the standards for medical service facilities of the basic
medical insurance,
and the medicine catalog, curing items of the
local supplementary medical insurance, when it provides medical
service.
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If
the fixed medical organization uses medicine, curing item and
medical service facilities out
of the range stipulated in the
preceding paragraph for the insured person, it shall ask him for
approval.
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Article
49
When the insured person goes to the fixed retail
drugstore to buy medicine with medical insurance certification,
the fixed retail drugstore shall comply with the following
provisions:
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1.
the person to sold over-the-counter medicines shall accord with
the provisions in paragraph 2
of Article 33 of these measures;
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2.
the sale of off-the-counter medicine shall according to the
prescription of the fixed medical
organization;
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3.
taking into account according to provisions on medical
insurance.
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Article
50
When the municipal organization of social insurance carry
out check and supervision, the fixed medical organization
and
the fixed retail drugstore have the obligation to provide
relevant materials and the detail
list of expense. If they do
not provide materials or the materials are not enough, the
municipal
organization of social insurance shall refuse to pay
corresponding expense. |
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Chapter 5
The Settlement of Medical Expense
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Article
51
The medical expense of the insured person, which occurred
from seeing a doctor or buying medicine and accords with
the
provisions of basic medical insurance, local supplementary
medical insurance or birth medical
insurance, shall be
transacted according to the following provisions based on the
certification
of medical insurance of the insured person:
|
1.
if it shall be paid from the overall fund of basic
medical insurance, the fund of local supplementary medical
insurance or birth medical insurance, the fixed medical
organization shall take it into account according
to the actual
amount;
|
2.
if it shall be paid from individual account, the fixed
medical organization or fixed retail drugstore shall transfer
and deduct the amount from the individual account of the insured
person. If the individual account
is not enough to pay off, it
shall collect from the insured person directly.
|
The
fixed medical organization, and the fixed retail drugstore shall
collect the charge, occurred
from seeing a doctor or buying
medicine, but not in the scope stipulated by the provisions of
basic
medical insurance, local supplementary medical insurance
or birth medical insurance, from the insured person directly.
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|
Article
52
The medical insurance premium may be settled by means of
service item, service unit, or illness category, or be paid
in
advance according to the total amount. |
The
municipal organization of social insurance shall establish
settlement method according to the
differences between medical
organization and the actual situation, and specify it in the
agreement
made between the municipal organization of social
insurance and the fixed medical organization.
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Article
53 The
insured person, who meets the requirements stipulated in Article
23 of these measures and whose
expense of outpatient service
shall be paid by the overall fund of basic medical insurance,
shall
go to the municipal organization of social insurance to
examine and reimburse the expense of outpatient service,
on the
basis of his medical record of outpatient service, detail list
of the expense, and the original
receipt of the expense within
the next year of medical insurance.
|
|
Article
54
If the insured person goes for emergency treatment in
other domestic city, or is approved to transfer into the
hospital in other domestic city, the medical expense of being in
hospital shall be examined and reimbursed
according to relevant
provisions, on the basis of relevant materials such as medical
record of
being in hospital, certification of diagnosis of out
of hospital or brief summary of out of hospital, definite and
detail list of the expense and the original receipt of expense.
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The
insured person with the permanent residence in the city, who is
sent to work in other domestic
city for a long time, or the
insured person who lives in other places after retirement, shall
examine
and reimburse their basic medical expense and local
supplementary medical expense occurred in the local fixed
organization of medical insurance, on the basis of relevant
materials such as medical record, certification
of diagnosis of
out of hospital or brief summary of out of hospital, definite
and detail list of
the expense and the original receipt of
expense.
|
If
the insured person goes abroad or be in hospital because of
emergency in Hong Kong, Macao or
Taiwan, he shall examine and
reimburse his medical expense
in the municipal organization of social insurance on the
basis of certification of his unit, passport for going abroad
or
special pass for Hongkong, Macau or Taiwan, medical record or
brief summary of out of hospital,
definite and detail list of
the expense and the original receipt of expense |
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Chapter 6
Supervising Medical Insurance
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Article
55
The supervisory organization of social insurance, which
is composed of representatives of governments, enterprises,
trade unions and other social organizations is established in
the city.
|
The
supervisory organization of social insurance supervises the
implementation situation of laws,
regulations and rules on
medical insurance, and supervises the income and outlay, usage
and management
of the fund.
|
|
Article
56
Every unit and individual has the right to impeach the
illegal or rule-breaking behaviors of the fixed medical
organization, fixed retail drugstore, insured person or the
working personnel of the municipal organization
of social
insurance.
|
The
municipal organization of social insurance shall reward the
impeacher. The amount of reward
shall be 20% of that of the
illegal amount, and shall be paid from the overall fund of basic
medical
insurance.
|
|
Article
57
The unit and insured person have the rights to inquire
about the situation of payment of medical insurance premium
and
treatment to the municipal organization of social insurance.
|
|
Article
58 The
unit participating insurance shall publicize the payment
situation of medical insurance premium
to employees once half a
year. |
|
Article
59
The municipal auditing organ shall audit the financial
payment and avenue of the fund of medical insurance timely
in
every year. The result of the auditing shall be reported to the
supervisory organization of
social insurance.
|
The
municipal organization of social insurance shall establish and
strengthen the financial system
and interior auditing system of
the fund of medical insurance.
|
|
Article
60
The administrative chief department of sanitary at all levels
shall strengthen the supervisory
and management to the fixed
medical organization, contain the implementation of medical
insurance
provisions in the check of comprehensive target
administration of fixed medical organization, and link it up
with the responsibility system of tenure target of the dean.
|
|
Article
61
The municipal administrative department of price shall
strengthen the supervisory on fixed medical organization and
fixed retail drugstore to carry out the policy on drug price and
medical service of the country,
province and municipality.
|
The
municipal administration department of medicine shall strengthen
the supervisory on the fixed
medical organization and the
quality of medicine of the fixed retail drugstore.
|
|
Article
62
The municipal organization of social insurance shall
carry out affiliated supervisory check to fixed medical
organization and fixed retail drugstore regularly or irregularly
jointly with relevant departments
of sanitary, price and
medicine.
|
Article
63
When the municipal organization of social insurance
carries out check, the checked unit shall report the situation
according to the facts, and provide relevant materials as
required, and shall not refuse being
checked, lie nor disguise. |
When
the municipal organization of social insurance checks the paying
situation of the insured unit,
it may require the unit to
provide materials, such as employment situation, wage schedule
and financial
table etc. concerning the payment of medical
insurance premium, and also may record on tape, film and paper,
take pictures and copy relevant materials but shall keep secret
for the unit checked.
|
|
Article
64
The municipal organization of social insurance shall
publicize the collection, payment, cash on hand and application
of the fund of social insurance audited timely in every year.
|
|
Article
65
The municipal organization of social insurance shall
establish the expert committee of medical insurance, and develop
the following activities:
|
1.
providing consultation for the municipal organization of
social insurance to make relevant policies
|
2.
providing skill guidance for the municipal organization of
social insurance to carry out supervision
and check on medical
insurance, and providing appraisal opinion on difficult medical
problems occurred
in the supervision and check.
|
3.
appraising the dispute between the insured person and the fixed
medical organization on leaving
hospital.
|
The
expenditure required by the expert committee of medical
insurance for activities shall be drawn
from the fund of medical
insurance collected in the same year by the municipal
organization of
social insurance according to the proportion of
less than 0.1%. |
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Chapter 7
Legal Responsibilities
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Article
66
If the employing unit does not pay the medical insurance
premium as stipulated, the municipal organization of social
insurance shall order it to correct in limited time. If it does
not correct in due time, it shall
be imposed a fine of 10% of
the medical insurance premium not paid or of the short amount
from
the order date.
|
If
the employing unit does not pay the evaded medical insurance
premium according to provisions,
the medical expense occurred in
the period shall be paid by the employing unit referring to the
provisions of these measures.
|
|
Article
67
If the insured unit provide medical insurance for person
not in the scope stipulated, the relation of medical insurance
is invalid, and the insured unit shall be imposed a fine of more
than 5000 yuan but less than 10000
yuan. As to charges having
been paid by the fund of social medical insurance, the municipal
organization
of social insurance shall take it back from the
insured unit; if the party consists a crime, he shall be
investigated criminal responsibility by judicial organ.
|
|
Article
68
Anyone, who violates the provisions of these measures,
does not register for social insurance, inform wrong number
of
insured persons, refuses to provide relevant materials or
provides untrue materials, shall be
ordered to correct in
limited time by the municipal organization of social insurance.
If he does
not correct in due time, the chief official of the
insured unit shall be imposed a fine of more than 2000 yuan but
less than 5000 yuan according to the seriousness of the
circumstances. |
|
Article
69
Anyone, who disturbs or obstructs the missionary of the
municipal organization of social insurance to perform official
duties, shall be punished by the department of public security
according to law. If he consists
a crime, he shall be
investigated criminal responsibility by the judicial organ.
|
|
Article
70
If the insured person commits anyone of the following
behaviors, the municipal organization of social insurance shall
take back the expenditures having been paid by the fund of
social medical insurance according to
law, and impose the person
directly liable a fine as much as the amount paid by the fund of
medical
insurance. If the behavior consists a crime, the
judicial organ shall investigate his criminal responsibility
according to law. |
1.
lending his identification of medical insurance to others
for seeing a doctor;
|
2.
falsifying medical record, prescription or furnish to get
extra money, or falsely claim the money as his own.
|
|
Article
71
If the fixed medical organization or the fixed retail drugstore
violates the medical insurance
agreement of the fixed medical
organization or of the fixed retail drugstore, the municipal
organization
of social insurance shall investigate its
responsibility of breach of contract according to the agreement.
|
|
Article
72
If the fixed medical organization commits anyone of the
following behaviors and causes the damage to the fund of
medical
insurance, it shall compensate the loss, and be imposed a fine
of more than 5,000 yuan
but less than 20,000 yuan by the
municipal organization of social insurance. If the circumstance
is very serious, its qualification of fixed medical organization
shall be suspended or revoked: |
1.
using the fund of medical insurance to pay the medical
expense of non-insured person;
|
2.
putting the medical expense ought to be paid by
individual in the range of expense ought to be paid from the
fund of medical insurance;
|
3.
embezzling the individual account of others;
|
4.
taking the unqualified insured person in hospital for
treatment, extending the period of in hospital at discretion,
allowing person to be in hospital only in name, making false
medical record, keeping business record
in subsection or taking
the insured person in over-standard sickroom without his
consent;
|
5.
using other means to increase the expense ought to be paid from
the fund of medical insurance.
|
The
person directly liable for the behaviors stipulated in the
preceding paragraphs shall be warned,
circulated a notice of
criticism or revoked his right of subscription of medical
insurance by the
municipal organization of social insurance
according to the seriousness of the circumstance. |
Article
73
The fixed retail drugstore violating the provision of
Article 49 of these measures shall be imposed a fine of more
than 1,000 yuan but less than 10,000 yuan by the municipal
organization of social insurance. If
the circumstance is very
serious, its qualification of fixed retail drugstore shall be
suspended
or revoked.
|
|
Article
74 The
fixed medical organization or the fixed retail drugstore
violating the provisions of price management
shall be punished
by the administrative department of price according to relevant
provisions.
|
The
fixed medical organization or the fixed retail drugstore
violating the regulation of medicine
management shall be
punished by the supervisory and administrative department of
medicine according
to relevant provisions.
|
|
Article
75
The working person of the municipal organization of
social insurance, who abuses his authority, neglects his duties,
or acts to serve his friends or relatives, shall be granted
administrative penalty by his employing
unit or relevant
department. If he causes damage to the fund of social insurance,
he shall shoulder
the responsibility of compensation. If his
behavior consists a crime, he shall be investigated criminal
responsibility by the judicial organ.
|
|
Article
76
If the party protests the notice of payment or the notice
of demand payment, the decision of punishment or the treatment
of medical insurance made by the municipal organization of
social insurance, he may apply for reconsideration
or bring
litigation according to law.
|
In
case that the employing unit does not pay the medical insurance
premium according to provisions,
or does not reimburse the
medical expense in the period of not paying the medical
insurance premium
according to these measures, the employee may
complain to the municipal organization of social insurance and
relevant department, and may apply for arbitration to the labor
arbitration organization. |
|
Chapter 8
Supplementary Provisions
|
Article
77
The average monthly wage of city-and-town employees of
the previous year in the whole city shall subject to the number
announced by the municipal statistical department. The average
monthly wage concerned in these
measures of the first half year
shall be calculated according to the average monthly wage of the
year before last, that of the second half year shall be
calculated according to the average monthly wage of the
previous
year.
|
|
Article
78 Employees in the branch or working offices established
out of the city by enterprises of the city shall participate
in
the basic medical insurance in the site of the offices.
|
The
medical insurance for foreigners and persons coming from
Hongkong, Macao or Taiwan, and employed
in the municipality
shall be transacted according to relevant provisions of the
country.
|
|
Article
79
Employing unit, who can not pay the medical insurance
premium in time because of special difficulty, may apply to
the
municipal organization of social insurance for deferred payment.
The municipal organization
of social insurance shall decide
whether or not to approve. The longest period for the deferred
payment approved shall not exceed 3 months.
|
The
insured person, whose standard of living is lower than the
lowest safeguard standard of living
of the municipality because
having paid too much medical expense, may apply to the municipal
organization
of social insurance for subsidies of basic medical
expense.
|
In
case that the payment of medical insurance premium is stopped
without the approval of the municipal
organization of social
insurance, the medical expense of the employee shall be paid by
the employing
unit referring to these measures.
|
|
Article
80
The employed person with registered permanent residence
in the municipality in individual economic organizations
shall
refer to these measures.
|
|
Article
81
The year of medical insurance begins at July 1 and ends
at June 30 of the next year.
|
|
Article
82
The specific measures on medical subsidies for public
servants and supplementary medical insurance for enterprises
shall be formulated by the municipal government separately.
|
|
Article
83
These measures shall go into effect as of July 1, 2003. |