rules of guangzhou municipality on social medical insurance  广州市司法局网站-凯发k8官方

　　(issued in accordance with decree no. 193 of the people’s government of guangzhou municipality on october 31, 2022 and put into force on december 1, 2022)

　　article 1     these rules are formulated in accordance with the social insurance law of the people’s republic of chinaand other relevant laws and regulations,on the basis of the actual conditions of this municipality, and with a view to regulating social medical insurance relations, safeguarding the legal rights and interests of the insured to enjoy social medical insurance benefits and promoting the healthy development of social medical insurance undertakings.

　　article 2     these rules are applicable to the coverage, service andregulationof social medical insurance and other related activities within the administrative areas of this municipality.

　　article 3     the municipal medical security authority shall be responsible for the social medical insurance related work and the organization of the implementation of these rules.

　　medical security agencies shall be responsible for the daily management and service for social medical insurance.

　　social insurance premium collection agencies shall be responsible for the collection of basic medical insurance premiums, and the supervision and inspection of the payers and their failure to pay the premiums in full and on time.

　　the authorities in charge of education, finance, human resources and social security, health and veterans affairs shall act ex officio for the social medical insurance work and coordinate with the implementation of these rules.

　　sub-district offices and town people’s governments shall assist medical security agencies and social insurance premium collection agencies in handling the registration of basic medical insurance for urban and rural residents under their respective jurisdiction and thecollection of premiums.

　　article 4      this municipality shall, in accordance with the rules of the state and guangdongprovince, establish and improve the basic medical insurance system for workers, thebasic medical insurance system for urban and rural residents, and the supplementary medical insurance systems including the , to meet the multi-level medical security needs of the insured workers and urban and rural residents.

　　each employer within the administrative areas of this municipality may establish a supplementary medical insurance system on its own behalf.

　　article 5    the basic medical insurance fund includes the basic medical insurance fund for workers and thebasic medical insurance fund for urban and rural residents, which shall be included in the special financial account of the social security fund.

　　the basic medical insurance fund for workers includes the generalbasic medical insurance fundfor workers and personal accounts.

　　the general basic medical insurance fund for workers and thebasic medical insurance fund for urban and rural residents shall be available with expenditure items as required.

　　the municipal finance authority shall, in conjunction with the municipal medical security authority, formulate a plan for maintaining and increasing the value of the basic medical insurance funds in accordance with national regulations and organize its implementation.

　　article 6      the employers within the administrative areas of this municipality shall participate in the basic medical insurance for their employees in this municipality.

　　freelancers with working places or registered permanent residencesin this municipality up to thenational or provincial standards may participate in the basic medical insurance for workers in this municipality.

　　workersdisabled for work-related reasons and identified as class i to class iv work-related disabilities, including those who retain labor relations and have gone through disability retirement procedures, receiving illness and disability allowances in this municipality, shall participate in the basic medical insurance for workers in this municipality.

　　the unemployed people filed for unemployment insurance in this municipalityshall participate in the basic medical insurance for workers in this municipalityduring the period of receiving unemployment insurance benefits.

　　article 7      the people from hong kong, macao or taiwan who arelawfully employed or recruited by the employers within the administrative areas of this municipality shall participate in the basic medical insurance for workers in this municipality as required by law. freelancers from hong kong, macao or taiwan withwork places or residences in this municiaplitywho have obtained residencepermits for hong kong, macao or taiwan residents mayparticipate in the basic medical insurance for workers in this municipality as required.

　　foreigners who have legally obtained relevant employment certificates and residence permits for foreigners and are legally employed in this municipality shall participate in the basic medical insurance for workers in this municipalityas required by national regulations.

　　article 8      the following persons who have not participated in the basic medical insurance for workers or have not enjoyed other safeguards as required shall participate in the basic medical insurance for urban and rural residentsin this municipality:

　　(1)  full-time students at primary/secondary schools, colleges/universities, secondary vocational schools, technical schools orscientific research institutes within the administrative areas of this municipality;

　　(2)  household registered population in this municipality;

　　(3)  holders of the guangdong provincial residence permit (within the validity period) issued by this municipality;

　　(4)  unemployed people from hong kong, macao or taiwan who live in this municipality and have obtained residence permits for hong kong, macao or taiwan residents;

　　(5)  other qualified personnel.

　　article 9     the employers within the administrative areas of this municipality shall, as required by law, go through the formalities for the payment and change of the basic medical insurance for their employees at the social insurance premiumcollecting agencies.

　　freelancers and retirees under extended premium payment terms may,at their own discretion, go to the social insurance premium collecting agencies to go through the payment and change procedures of basic medical insurance for workers.

　　article 10   persons who participate in the basic medical insurance for urban and rural residents may go through the registration and change procedures of basic medical insurance for urban and rural residents at the sub-district offices or the town people’s governments or at the local colleges/universities, secondary vocational schools, technical schools or scientific research institutes.

　　persons who participate in the basic medical insurance for urban and rural residents shall go through the insurance registration and premium payment formalities within the prescribed time, and pay for thebasic medical insurance for urban and rural residents in full subject to the medical insurance year.

　　personswith the history of participating in the basic medical insurance for urban and rural residents in the previous medical insurance year do not need to go through the insurance registration procedures againin the current medical insurance year; once they pay for thebasic medical insurance for urban and rural residentsfor the current medical insurance year, the insurance relationship will be automatically renewed.

　　during the medical insurance year, urban and rural residents inany of the following situations can register and pay for thebasic medical insurance for urban and rural residents for the current medical insurance year:

　　(1)  those whose filing for basic medical insurance for workers is suspended;

　　(2)  full-time students transferred to study in this municipality from schools outside the administrative areas of this municipality;

　　(3)  new-born babies;

　　(4)  newly settled residents;

　　(5)  newly confirmed recipents of medical aids;

　　(6)  veterans;

　　(7)  emancipists;

　　(8)  other personsidentified by medical security agencies to be the ones who need to register and pay for medical insurance in the current medical insurance year.

　　article 11     the employers within the administrative areas of this municipality shall pay for medical insurance in full on a monthly basis, and withhold the premiums for basic medical insurance for workers that should be paid by their employees individually.

　　freelancers who pay for the basic medical insurance for workersshall pay the premiums in full on a monthly basis; retirees under extended premiums payment terms who pay for the basic medical insurance for workers shall pay the premiums in full on a monthly basis or in a lump sum.

　　the insured of the basic medical insurance for workers may simultaneously participate in the large medical expense allowance for workers.

　　article 12     from the month following the termination of payment of premiums for basic medical insurance for workers, the employees shall cease to enjoy the general benefits of basic medical insurance for workers and the large medical expense allowance for workers, which shall cease to be included in the funds of personal accounts, but the balance of personal accounts may continue to be used.

　　for an employer within the administrative area of this municipality that fails to participate in the basic medical insurance for workers for its employees or fails to pay for the basic medical insurance for workers in full and on time, where it makes up the payable premiums and late fees in full within three months (calculating from the month following the failure to participate in the basic medical insurance for workers as required or the month following the failure to pay insurance premiumspayable in full and on time), the general benefits of basic medical insurance for workers and the large medical expense allowance for the corresponding period of the supplementary payment shall be made subsequently from the general basic medical insurance fund for workers; where the payable premiums and late fees are paid after 3 months from the payable date, general benefits of basic medical insurance for workers and the large medical expense allowance will not be made up from the general basic medical insurance fund for workers.

　　after the employer has made the supplementary payment in accordance with the provisions of the preceding paragraph, the cumulative payment years of the insured employees in this municipality shall be added accordingly, and the benefit funds for the corresponding period of supplementary payment shall be credited to the personal account of the insured employees according to the applicable personal account appropriation standard.

　　supplementary payment of premiums is prohibited for freelancers and retirees under extended premiums payment terms who fail to pay for basic medical insurance for workers on time and in full, unless otherwise provided for by national or provincial regulations.

　　article 13  for retirees certified by social insurance agencies to receive basic pensionswho have paid premiums for a cumulative period under the number of years prescribedby the state or this municipality, they shall be entitled to the special funds provided by the people’s governments at different levels according to the following standards in terms of the premiums for basic medical insurance for workers payable for the remaining number of years, after deducting the parts calculated and paid by the employers according to the original provisions: where an individual participating in the endowment insurance in this municipality has contributed premiums for a cumulative period of 25 years(including deemed endowment insurance premium contributionyearsas per provision of this municipality, as well as the contributionyears and deemed contributionyears of the central or provincial offices in this municipality’s administrative areas participating in endowment insurance at the provincial social insurance agencies), the premiums for basic medical insurance for workers payable shall be paid in full from the government’s special funds in a lump sum; where an individual participating in the endowment insurance in this municipality has contributed premiums for a cumulative period of over 20 years but less than 25 years, the premiums for basic medical insurance for workers payable shall be paid 50% by the government’s special fund, and 50% by the individual; where an individual participating in the endowment insurance in this municipality has contributed premiums for less than 20 years, the premiums for basic medical insurance for workers payable shall be paid in full by the individual. the deadline for calculating the contributionyears of endowment insurance premiums is determined by the preceding month when the medical insurance system is launched in the original independent general fund area where the individual goes through theformalities for receiving basic pension. the specific deadlinesare as follows: february 2006 for huadu district, april 2003 for panyu district, december 2005 for conghua district, november 2005 for zengcheng district, november 2001 for other districts of this municipality, and september 2004 for china railway guangzhou group co.,ltd.

　　for retirees who have registered residence in this municipality, are re-employed when aged over 50 years old (for male) or 40 years old (for female) and retired in the new work places, the premiums for basic medical insurance for workers payable for the remaining number of years that should be paid by individuals at the retirement, shall be paid fromthe special funds provided by people’s governments at different levels with reference to the provisions of the preceding paragraph.

　　for persons transferred from outside the municipality as organized by this municipality and approved by the municipal human resources and social security authority, and the military cadre transferred to civilian work, demobilized cadres, demobilized conscripts, non-commissioned officers transferredto civilian work, military cadres’ dependents and other personnel who are approved to be resettled in this municipality, the contributionyears of endowment insurance premiums (including the deemed contributionyears) transferred from outside the municipality shall be included in the contributionperiods for enjoying the government’s special funds.

　　the government subsidies for the insured to participate in the basic medical insurance for workers shall be fully borne by the finance at the same level according to the affiliation of the work place where the insured has worked the longest time in the administrative areas of this municipality.

　　article 14     the specific contribution base and financing standards for basic medical insurance for workers, large medical expense allowance for workers, basic medical insurance for urban and rural residents and serious disease insurance for urban and rural residents shall be separately formulated by the municipal medical security authority in conjunction with the municipal finance authority, and shall not be implemented unless approvedby the municipal people’s government.

　　article 15     the insured of the basic medical insurance for workers shall be entitled to the general benefits of the basic medical insurance for workers and the benefits of personal accounts. the overall benefits of basic medical insurance for workers include hospitalization benefits, insurance benefits for outpatient-specific diseases and insurance benefits for general outpatient services.

　　the employees who participate in the basic medical insurance may enjoy large medical expense allowance for workers at the same time.

　　the insured of the basic medical insurance for urban and rural residents shall be entitled to the general benefits of the basic medical insurance for urban and rural residents, including hospitalization benefits, insurance benefits for outpatient-specific diseases,insurance benefits for general outpatient services,and maternity health benefits.

　　the insured of the basic medical insurance for urban and rural residents may enjoy the serious disease insurance benefits for urban and rural residents at the same time.

　　article 16     the payment of hospitalization expenses, basic medical expenses of outpatient-specific diseases and general outpatient services from the general basic medical insurance fund for workers and the basic medical insurance fund for urban and rural residents shall comply with the relevant provisions of the drug catalogue, medical consumables catalogue, medical service items and other catalogues for the basic medical insurance as well as payment standards and payment scope.

　　the payment of maternity related medical expenses from basic medical insurance fund for urban and rural residents shall comply with the relevant provisions of the drug catalogue, medical consumables catalogue, medical service items and other catalogues for the maternity insurance as well as payment standards and payment scope.

　　the medical expenses out of the payment scope of the general basic medical insurance fund for workers and the basic medical insurance fund for urban and rural residents shall be subject to national or provincial regulations on medical insurance benefits.

　　article 17     the specific payment standards and measures for benefits of basic medical insurance for workers, large medical expense allowance for workers, basic medical insurance for urban and rural residents and serious disease insurance for urban and rural residents shall be formulated separately.

　　the inclusion standard and management of the personal accounts of insured employees shall be implemented in accordance with the provincial regulations.

　　article 18   where an individual participating in the basic medical insurance for workers has paid premiums for a cumulative period reaching the number of years prescribed by the state and this municipality when he/she reaches the statutory retirement age, he/she, upon approval by the medical security agency, shall enjoy the benefits of basic medical insurance for workers from the next month after reaching the statutory retirement age.

　　for an individual participating in the basic medical insurance for workers who has paid premiums for a cumulative period under the number of years prescribed by the state and this municipality when he/she reaches the statutory retirement age, if he/she chooses to pay premiums on a monthly basis until the number of years prescribed by the state is reached, he/she shall be entitled to the general benefits of the basic medical insurance for workers as per the standards of serving staff during the extended premiums payment terms; if he/she chooses to make lump sum payment for the remaining prescribed number of years, he/she shall be entitled to the benefits of basic medical insurance for workers for retirees from the next month after payment.

　　for the insured who has not reached the statutory retirement age, has been coordinated to work in this municipality from other overall planned areas, and has transferred the insurance relationship for basic medical insurance for workers to this municipality according to the national and provincial regulations, the premium payment years of the basic medical insurance for workers in other overall planned areas shall be incorporated into the cumulative payment years.

　　the period that a freelancer has paid for the basic medical insurance for urban and rural residents in this municipality shall be incorporated into the cumulative payment period of the basic medical insurance for workers in this municipality.

　　the number of years of servicemen in active service shall be deemed as the cumulative payment years of basic medical insurance for workers in this municipality, and the payment period of basic medical insurance for workers before enlistment and after being discharged from active service shall be incorporated into the cumulative payment period of the basic medical insurance for workers in this municipality.

　　the cumulative payment years include the accumulated payment years in this municipality and in other overall planning areas.

　　article 19   when the insured goes to a designated medical institution for medical treatment or a designated retail pharmacy to purchase medicine, he/she shall present valid basic medical insurance certificates and act as instructed by the designated medical institution and the designated retail pharmacy in identity verification. where the valid basic medical insurance certificate is not presented during the expense settlement, the expenses incurred thereby shall be solely borne by the insured.

　　article 20  for the insured who requires hospital stay for medical treatment based on the diagnosis by the doctors of a designated medical institution, he/she may choose any designated medical institution providing hospitalization services in this municipality at his/her own discretion.

　　the insured shall act as instructed by the designated medical institutions in implementing the admission and discharge standards and hospitalization management regulations stipulated by the health authority. where the insured meets the discharge standard but refuses to discharge as required, the expenses incurred from the day following the discharge date specified on the physician’s order sheet of the designated medical institution will not be paid from the general basic medical insurance fund for workers or the basic medical insurance fund for urban and rural residents.

　　article 21  for the basic medical expenses for each hospitalization of the insured, the amount above the deductible line shall be paid from the general basic medical insurance fund for workers and the basic medical insurance fund for urban and rural residents in accordance with the related provisions, and the amount below the deductible line shall be borne by the insured.

　　where the designated medical institution handles transfer formalities for the insured according to the clinical transfer standard, the expenses of the insured above the deductible line shall be calculated as one hospitalization. if the deductible line of the transferred hospital is higher than that of the transferring hospital, the insured shall pay the difference between the deductible lines of the two hospitals; if the deductible line of the transferred hospital is lower than that of the transferring hospital, there is no need to pay the difference.

　　article 22    where an individual who has participated in the basic medical insurance for urban and rural residents pays for the basic medical insurance for workers in the medical insurance year, he/she shall begin to enjoy the corresponding benefits of basic medical insurance for workers from the month following the payment of the basic medical insurance for workers, and shall no longer enjoy the benefits of basic medical insurance for urban and rural residents during the period of enjoying the benefits of basic medical insurance for workers.

　　in case of any change in the basic medical insurance that the insured has participated in during the medical insurance year, the medical expenses incurred during different basic medical insurance periods shall be calculated separately, and the annual maximum payment limit shall be accumulated separately.

　　where the basic medical insurance type that the insured participates in changes during his/her hospitalization, the designated medical institution shall handle the settlement of medical expenses by stages. the standard of medical insurance benefits effective at the time of settlement shall prevail, the deductible line shall be calculated only once according to the basic medical insurance that the insured person participated in at the time of admission, and the medical security agency shall calculate the number of inpatients separately for the designated medical institution.

　　article 23  the medical expenses incurred by the insured in the designated medical institutions and the designated retail pharmacies shall be settled by the medical security agency with the designated medical institutions and the designated retail pharmacies according to the medical expense settlement standards and methods.

　　the medical expense settlement standards specified in the preceding paragraph shall be formulated and adjusted in due time by the municipal medical security authority according to the economic and social development levels, changes in the price of medical services, the medical technology development level, and the balance of the basic medical insurance funds. the medical expense settlement methods and measures specified in the preceding paragraph shall be separately formulated by the municipal medical security authority in conjunction with the municipal finance authority and the municipal health authority.

　　article 24    where the insured’s continuous hospitalization and receiving treatment for outpatient-specific diseases covers two medical insurance years, the medical expenses incurred by the insured in the previous year shall, in principle, be transferred to the current medical insurance year for settlement; if the insured needs to calculate annual medical expenses, the designated medical institution shall apply to the medical security agency for staged settlement. the deductible line for payment from the general basic medical insurance fund for workers and from the basic medical insurance for urban and rural residents shall be calculated according to the standard of the year when the insured is admitted or begins to receive medical treatment.

　　article 25  the following terms herein shall convey the meanings as defined below:

　　(1)    the term “medical insurance year” shall refer to the period from january 1 to december 31 of each year.

　　s shall refer to an individual participating in the basic medical insurance for workers who has contributed premiums for a cumulative period under the number of years prescribed by the state or this municipality when he/she reaches the statutory retirement age, and chooses to continue to pay the premiums until the number of years prescribed by the state is reached.

　　 shall refer to those having reached the statutory retirement age who are not on the job and have been approved by the social insurance agencies within the administrative areas of this municipality to receive the basic pension of employees’ pension insurance on a monthly basis.

　　(4)    the term “” shall refer to the medical expenses incurred by the insured who go to the outpatient (emergency) clinic in accordance with the regulations that are in conformity with the diseases, specific treatment items and relevant access standards published by the medical security authorities and belong to corresponding drug catalogue for the medical insurance, which shall be paid from as per the specified proportion.

　　(5)    the term “” shall refer to the medical expenses incurred by the insured who go to the outpatient (emergency) clinic in accordance with the regulations that are not covered by the insurance benefits for outpatient-specific diseases and shall be paid from the general basic medical insurance fund for workers and the basic medical insurance fund for urban and rural residents as per the specified proportion.

　　 shall refer to the medical expenses that are in conformity with the national and provincial drug catalogue, medical consumables catalogue, medical service items and other catalogues for the basic medical insurance as well as payment standards and are within the payment scope, excluding the expenses that shall be paid by individuals in accordance with the prescribed proportion and the expenses exceeding the cap.

　　article 26 these rules shall come into force on december 1, 2022. the measures of guangzhou municipality for social medical insurance (decree no. 123 of the people’s government of guangzhou municipality) shall be abolished accordingly