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Interim Procedures of Shanghai Municipality on Medical Insurance on Outpatient and Emergency Treatment for Retired Persons
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| (Approved by the Shanghai Municipal People' s Government on October 6, 1998) Article 1 (Purpose and Basis) With a view to ensuring the basic medical needs of the retired persons in town enterprises in respect of outpatient and emergency treatment, and perfecting step by step the municipal medical insurance system, these Procedures are formulated in the light of the Reform Program of Shanghai Municipality on Medical Insurance System for Workers and Staff Members in the Town Enterprises. Article 2 ( Scope of Application) These Procedures apply to the town enterprises in this Municipality as well as to their retired persons. The term "retired persons" used in these Procedures refers to those in the enterprises mentioned above who have gone through retirement formalities and received a monthly pension granted by a social insurance organ in accordance with the relative State and Municipal regulations. Article 3 (Medical Insurance Principle of Outpatient and Emergency Treatment) Medical insurance on outpatient and emergency treatment for the retired persons shall be practiced in conformity with the principle of overall social planning, mutual aid, guarantee of basic medical need, medical treatment convenience, and waste avoidance. Article 4 ( Payment Scope of Medical Insurance Fund) Medical Insurance Fund shall pay proportionally, as stipulated in Section 1 of Article 5 of these Procedures, the medical expenses of the retired persons for outpatient and emergency treatment other than those items stipulated in the Interim Procedures of Shanghai Municipality on Medical Insurance on Outpatient and Emergency Treatment Items for Workers and Staff Members in Town Enterprises . Article 5 (Payment and Share of Medical Expenses) Medical Insurance Fund shall pay 50 percent of the medical expenses of the retired persons which result from each outpatient or emergency treatment and meet the requirements of medical insurance scope, items and expense standards. The other 50 percent shall be shared reasonably by the enterprises and the retired persons in question according to the classification of the medical organs (Grade I, II or III) where the retired persons have received medical treatment; the Municipal Medical Insurance Bureau shall lay down the specific share proportion separately in consultation with the relevant departments. Enterprises shall not be in arrears without reason with their stipulated shares in the outpatient and emergency medical expenses of the retired persons. Article 6 (Payment of Special Medical Item Expenses) The Municipal Medical Insurance Bureau can lay down some corresponding payment provisions for the retired persons' adoption of costly examinations and treatments or use of expensive imported materials and medicines in the course of the outpatient or emergency medical treatments. Article 7 (Medical Treatment) Retired persons may go to the medical institutions their enterprises have appointed (hereinafter referred to as appointed medical institutions) when they need outpatient or emergency medical treatment. The Municipal Medical Insurance Bureau may lay down the scope of appointed medical institutions separately. Retired persons of this Municipality living in other provinces or cities may go to the local state-owned or collective-owned medical institutions their enterprises have appointed when they need outpatient or emergency medical treatment. Retired persons may go to the nearby medical institutions other than those stipulated in Section 1 and Section 2 of this Article when they need emergency medical treatment. Article 8 (Medical Treatment Certificates) Retired persons shall show their medical insurance certificates and their relevant identity cards when they go to the appointed medical institutions for outpatient or emergency treatment and the appointed medical institutions shall have a careful check thereof. Appointed medical institutions shall detain or copy the number of any medical service insurance certificate that is found faked, falsely used or altered and report promptly to the district or county medical insurance office as well as to the enterprise in question. Article 9 (Service Norms of Medical Institutions) Appointed medical institutions shall practice rational treatment, examination, prescription and charge as required by the respective cases of the retired persons in accordance with the stipulation of medical insurance scope and items as well as of relevant medical treatment standards. Article 10 (Management of Medical Files) Appointed medical institutions shall keep the medical files of the retired persons' outpatient or emergency treatment and provide corresponding data that meet the requirements of the medical insurance verification and account settlement in accordance with the relevant State and Municipal regulations. Article 11 (Accounting) Appointed medical institutions shall keep accounts of the retired persons' medical expenses occurring in the course of their outpatient or emergency treatment in accordance with the stipulated medical insurance scope, items and expense standards. Article 12 (Account Settlement and Verification) Appointed medical institutions shall apply to the assigned district and county medical insurance offices for settlement of the part of medical expenses that are charged to an account and are to be paid by medical insurance fund in accordance with the stipulated medical insurance scope, items and expense standards. The Municipal Medical Insurance Bureau shall lay down separately settlement procedures on the retired persons' medical expenses occurring in the course of emergency treatment in non-appointed medical institutions or medical institutions in other provinces or cities. Article 13 (Medical Insurance on Outpatient and Emergency Treatment for Other Retired Persons) Medical insurance on other retired persons' outpatient or emergency treatment, which the Municipal Medical Insurance Bureau has formulated in consultation with the relevant departments, shall be implemented in accordance with these Procedures. Article 14 (Other Items) Managerial items other than those covered in these Procedures shall be implemented in accordance with the relevant regulations in the Interim Procedures of Shanghai Municipality on Medical Insurance on Hospitalization for Workers and Staff Members of Town Enterprises. Article 15 (Department for Interpretation of Application) The Municipal Medical Insurance Bureau is responsible for the interpretation of the specific application of these Procedures. Article 16 (Date of Implementation) These Procedures shall become effective on November 1, 1998. |
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