In order to facilitate the insured people to understand the medical insurance policy
Huoqiu County Medical Security Bureau
Launched by insurance type, type and topic
Medical Insurance Policy "Understanding Paper"
Today's interpretation for you is
"Medical Insurance Policy "Understanding Paper" - Medical Insurance for Urban Employees
01
Payment, transfer, and change of insurance premiums
Q
1. Who should participate in the basic medical insurance for employees?
All urban employers within the city, including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises, private enterprises, etc.), government organs, public institutions, social organizations, private non-enterprise units, and their employees, must participate in the basic medical insurance for employees, and the employers and employees shall jointly pay the basic medical insurance premiums in accordance with state regulations. Individual industrial and commercial enterprises without employees, part-time employees who do not participate in the basic medical insurance for employees at the employer, and other flexible employment personnel may participate in the basic medical insurance for employees, and the individual shall pay the basic medical insurance premiums in accordance with the provisions of the State.
Q
2. How is the payment of employee medical insurance regulated?
The employer shall use the total salary of the employees of the previous year as the contribution base, and the employer rate shall be 7%. (Note: From April 1, 2020, the basic medical insurance for urban employees and maternity insurance in Lu'an City will be implemented together, and employers and employees in Lu'an City should participate in the basic medical insurance and maternity insurance for employees at the same time, and register for insurance in a unified manner.) If the average monthly salary of the previous year is used as the contribution base, and the individual employee's salary is lower than 60% of the average salary of the employed persons in the province's full-caliber urban units in the previous year, the contribution shall be calculated on the basis of 60% (the current minimum contribution base is 3832 yuan); Above 300%, the payment will be calculated on the basis of 300% (the current maximum base is 19160 yuan). Individual rates are 2%. Flexible employment personnel take 60% of the average salary of employed persons in full-caliber urban units in the province in the previous year as the contribution base (currently 3832 yuan), and if there is no personal account, the contribution shall be paid at a rate of 5.5%; If you set up an individual account, you will pay at a rate of 8.5%. Flexible workers are not covered by maternity insurance. Insured persons who participate in the basic medical insurance for employees also participate in serious illness medical assistance (including retirees), and the unit or individual pays the serious illness medical assistance insurance premium according to the prescribed standards. The current payment standard of Lu'an City Serious Illness Relief Fund: 12 yuan/month/person. The employer and the employee pay the basic medical insurance premium on a monthly basis, and the individual contribution part is withheld and paid by the employer. Flexible employment personnel are withheld and paid on a monthly basis through the agreement bank.
Q
3. How does the employer handle the procedures for employee medical insurance enrollment (suspension)?
There are two ways for the participating units in Lu'an City to apply for medical insurance for their employees. (1) Apply online. Log in to " Anhui Medical Insurance Public Service Platform "
https://ybj.ahzwfw.gov.cn/hsa-pss/hallEnter/authCode=40d50e48-0d88-4abd-82ac-0d65b0edee75#/Index, select "Unit", log in through the legal person user of the government service network, enter the online office hall of the unit, the new insurance enrollment of unit personnel, and the renewal interface of unit personnel (Note: If the employee has participated in employee medical insurance in Lu'an City, Please select Renewal; Please select the new enrollment for the first time to enroll) to add, fill in the required items and click OK to display that the information is submitted successfully; The suspension of insurance for employees can be handled on the personnel suspension interface of the unit. (2) Offline processing. Download the employee increase or decrease form (in duplicate) on the website of the Lu'an Medical Security Bureau (or the medical insurance QQ group) or go to the medical insurance window of the local government service center to obtain the increase or decrease of personnel (in duplicate), fill in the relevant information of the insured employees, and then affix the official seal of the unit to go through the procedures for increasing or reducing employees at the medical insurance window.
Lu'an flexible employment personnel can participate in employee medical insurance can be applied for online on the Anhui Medical Insurance Public Service Platform, or offline with valid identity documents to go to the medical insurance window of the local government service center to complete insurance payment or suspension procedures. (Note: On-site processing is the working day of the 1-20th of each month; Online application is held on the 1st-25th working day of each month)
Q
4. When can an insured employee enjoy medical insurance treatment after successful normal payment?
(1) Flexible employment insurance participants shall enjoy medical insurance treatment according to regulations from the seventh month after paying medical insurance premiums for the first time (account establishment month), and implement monthly payment of medical insurance premiums (simultaneous payment of serious illness relief insurance), and if they fail to pay on time, they will be regarded as arrears in medical insurance premiums. Flexible workers are not covered by maternity insurance. Insured persons who terminate their labor relationship with their work unit or whose period of receiving unemployment insurance money expires may continue their medical insurance relationship in their individual capacity. (2) Unit participation: The insured personnel who participate with the employer shall enjoy the medical insurance treatment according to the regulations from the month following the first payment of medical insurance premiums. Maternity insurance: If the insured pays contributions continuously for 6 months or more at the employer before giving birth, he or she can enjoy maternity insurance treatment according to regulations (the employer is not entitled to maternity allowance when fully funded by the government).
Q
5. When does an insured employee start to lose medical insurance benefits after defaulting on medical insurance premiums? When do I start to enjoy the benefits after paying the arrears?
In view of the time lag between the collection budget of the medical insurance department and the data transmission of tax collection, the system of the unit or flexible employment personnel who have arrears for more than one month has enabled the blocking function of the unit's medical treatment, and the employees of the unit will be suspended from the month following the arrears of payment. The scope of the blockade is: hospitalization, chronic disease subsidies and medical insurance benefits covered by the pooled fund for all insured persons of the unit. If there is a suspension of participation for less than three months, the medical insurance treatment will be unblocked when the first payment is received after the renewal of the supplementary payment, that is, the blockade termination period is the time of the first arrival; If there is a three-month interruption of enrollment, the system will change the termination period of the blocked information when the person suspends the insurance to the renewal date after the renewal of the supplementary payment, and generate a new personal medical blocking information, the blocking period is half a year, and the blockade start period is the renewal date. Medical expenses incurred during the arrears period are not covered by the Medical Insurance Fund (i.e. not reimbursed).
Q
6. How to transfer the medical insurance relationship to Lu'an City if I was originally insured abroad? If the medical insurance relationship is transferred to our city, how long can the transfer procedure be completed?
The Lu'an medical insurance handling institution shall issue the "Basic Medical Insurance Relationship Transfer Contact Letter" to the original participating place within 15 working days after receiving the "Basic Medical Insurance Participation Certificate" issued by the applicant, and the Lu'an medical insurance handling institution shall handle the connection of insurance relationship and funds within 15 days after receiving the "Information Form for Change of Medical Insurance Type of Insured Personnel" issued by the original participating place and the amount of the basic medical insurance personal account.
Q
7. How can employees in our city transfer their medical insurance relationship to other places? How to transfer the balance of the medical insurance personal account if the medical insurance relationship is transferred to a foreign country?
After the basic medical insurance relationship for employees is suspended, the medical insurance handling institution of Lu'an City issues the "Basic Medical Insurance Participation Certificate" to the applicant, and the new participating place will issue the "Basic Medical Insurance Relationship Transfer Contact Letter" within 15 working days after receiving the "Basic Medical Insurance Participation Certificate"; and the Lu'an City medical insurance handling institution will issue the "Basic Medical Insurance Relationship Transfer Contact Letter" issued by the new participating place within 15 working days to the new participating place the "Information Form for Change of Medical Insurance Type of Insured Personnel" for employees in our city. And simultaneously transfer the amount of the basic medical insurance personal account to the bank account of the medical insurance agency in the new participating place, and the employee medical insurance information and personal account amount will be entered by the new participating place.
Q
8. How do employees in our city issue an "Insurance Certificate"?
After the basic medical insurance relationship of employees is suspended, they can issue an individual "Certificate of Participation" in the following ways: first, go offline to the medical insurance agency in Lu'an City, and issue it with their valid identity documents; The second is to log in to the Anhui Medical Insurance Public Service Mini Program online, select [Lu'an City], and choose to issue a personal insurance certificate on the business handling page.
Q
9. How to transfer medical insurance in Anhui Province to Lu'an City online for continuation?
First of all, you pay attention to the "Lu'an Medical Security Bureau" WeChat public account released by the mobile phone, click the "Medical Insurance Hall" in the lower left corner of the main page, and click "Anhui Medical Insurance Public Service". (1) Select the place of insurance in the upper left corner [Lu'an City], then click "Medical Insurance Electronic Voucher" on the home page, check "You agree to use the medical insurance electronic voucher and convey relevant data for medical insurance service inquiry" on the pop-up interface, and click [Authorization Inquiry] for authentication. (2) Click [Basic Medical Insurance Transfer Application (Province)] in the business handling to enter the application interface. (3) In the application interface for the transfer of basic medical insurance relationships in the province, improve the information of the institutions in the place of transfer, confirm the information of the institutions of the place of transfer, upload the insurance certificate, and click [Submit] to complete the application for the transfer of basic medical insurance relationships from cities inside and outside the province to Lu'an City. (4) How to obtain the certificate of participation: You can select the transfer region on the home page of the Anhui Medical Insurance Public Service Mini Program and download the certificate of participation in the insurance information in the personal service (Note: the participation information of the transfer area can only be downloaded if the participation is suspended).
Q
10. What are the application materials for opening an account for medical (maternity) insurance units in Lu'an City?
(1) Two copies of the registration form for the participation of the urban employee medical (maternity) insurance unit in Lu'an City (the form window can be obtained); (2) A roster of new personnel declaration for urban employee medical (maternity) insurance in Lu'an City (at least one new insured person must be added when opening an account, no empty account can be opened, and the form window can be collected); (3) Copy of business license; (4) A copy of the ID card of the legal representative; (5) Salary flow or schedule of the insured. (Remarks: The tax supervisory unit opens an account directly in the city for the development zone)
Q
11. What are the application materials for the reduction of the last insured person of the unit and the cancellation of the medical insurance account of the unit?
Lu'an City's urban workers' medical (maternity) insurance reduction personnel declaration roster (the form window can be obtained), tax clearance or tax payment certificate issued by the tax department, and a copy of the business license.
Q
12. How is the personal account of the insured person configured?
(1) Allocation standards: (1) Retirees: In principle, the overall fund will be transferred to a fixed amount, and the amount will be gradually adjusted to 2 percent of the average level of the basic pension in the year when the reform is implemented in accordance with the "Anhui Province Implementation Measures for Establishing and Improving the Outpatient Mutual Aid Security Mechanism for Basic Medical Insurance for Employees." From July 1, 2022, it will be credited to the personal account at 70 yuan per month, and will be adjusted in accordance with national regulations in the future. (2) In-service personnel: The basic medical insurance premiums paid by individuals are included, and the inclusion standard is in principle controlled at 2% of the payment base of their own insurance. (2) Configuration time: The medical insurance information system automatically configures personal accounts on a monthly basis according to the payment status of the insured.
Q
13. How to handle the retirement of flexible employees?
In the same month, send SMS and social security card to the medical insurance window to apply for medical insurance retirement with the social security pension, and accept the application for a single month of retirement treatment on the day of medical insurance retirement. When the insured personnel in our city retire, the minimum payment period for them to participate in basic medical insurance is the 30th anniversary of men and 25 years for women. If there is a foreign insurance period, the transfer procedures need to be completed half a year in advance, otherwise the retirement benefits of medical insurance will be affected.
Q
14. How to handle the retirement of enterprise personnel?
Before the 20th of the month of the month, the retiree of the unit shall go to the medical insurance window to apply for retirement benefits in the following month with the "Application Form for On-the-Job Transfer and Retirement" and the retirement approval document or the suspension of salary roster. Retirees who retire as individuals contact the unit to suspend the insurance in the month and after the suspension of insurance, then bring the social security card and retirement approval or approval number to the medical insurance window for processing. When the insured personnel in our city retire, the minimum payment period for them to participate in basic medical insurance is the 30th anniversary of men and 25 years for women. If there is a foreign insurance period, you need to go through the transfer procedures half a year in advance, otherwise it will affect the retirement benefits of medical insurance.
02
Outpatient and inpatient expense reimbursement
Q
15. What is the standard for transferring the personal account of urban employees' medical insurance?
From July 1, 2022, the province's unified employee outpatient mutual aid guarantee policy will be implemented, and the insured employees (including institutions, enterprises and institutions, flexible employment personnel, etc.) who participate in the unified account combination mode will be credited to their personal accounts according to 2% of their own payment base; Retired employees will be credited to their personal accounts at 70 yuan per month, and will be dynamically adjusted in accordance with national regulations in the future.
Q
16. What is the scope of outpatient mutual assistance coverage of basic medical insurance for employees?
Medical expenses incurred by employees in the general outpatient clinics of designated medical institutions (except emergency and rescue), as well as within the scope of the policy of dispensing drugs outside the prescription of outpatient clinics of eligible retail pharmacies, shall be paid by the employee medical insurance pooling fund according to regulations.
Q
17.What is the scope of use of employees' personal accounts?
Family members (spouses, parents, and children) can use their personal accounts to pay medical expenses within the scope of the policy, and family members participating in domestic medical insurance, etc., can also pay with personal accounts.
Q
18. After completing the retirement procedures, when will employees start to enjoy the outpatient mutual assistance security treatment of retirees?
From the month following the retirement procedures, employees can enjoy the personal account crediting of retired employees and the treatment of outpatient mutual assistance, and the minimum payment standard for ordinary outpatient expenses is calculated continuously.
Q
19. Are retirees relocated or long-term residents in other places entitled to outpatient mutual assistance protection of basic medical insurance for employees?
"Resettlement retirees, long-term residents, and resident staff in other places" who have gone through the filing procedures can enjoy the general outpatient guarantee treatment in the filing place, and the specific treatment standards shall be implemented with reference to the city's general outpatient reimbursement policy.
Q
20. What is the threshold for hospitalization of basic medical insurance for urban employees?
In one year, the minimum payment standard of the first hospitalization pooling fund is unified: 400 yuan for first-level hospitals, 600 yuan for second-level hospitals, and 900 yuan for tertiary hospitals; The minimum payment standard of the second and above hospitalization pooling fund is 300 yuan for first-level hospitals, 500 yuan for second-level hospitals, and 800 yuan for tertiary hospitals. The minimum payment standard for transferring to hospitals outside the city is 1200 yuan.
Q
21. What is the personal out-of-pocket payment rate for insured urban employees during hospitalization?
In one year, the insured person who meets the inpatient medical expenses stipulated by the basic medical insurance shall pay up to the maximum payment limit of the basic medical insurance, and the insured employee will pay 6% for the first-level hospital, 8% for the second-level hospital, and 10% for the third-level hospital; Retirees pay 4% out of pocket in primary hospitals, 6% in secondary hospitals and 8% in tertiary hospitals.
Q
22. What is the annual cap of basic medical insurance for urban employees?
For medical expenses paid by employees' medical insurance, the annual actual payment limit of the basic medical insurance pooling fund for employees is 100,000 yuan. The part above the annual maximum payment limit of basic medical insurance is paid by the medical aid fund, and the payment limit is 250,000 yuan (including 100,000 yuan for basic medical insurance).
03
Critical illness insurance reimbursement
Q
23. What is the minimum payment line, reimbursement ratio and annual cap line of serious illness insurance for urban employees?
The minimum payment line of serious illness insurance for urban employees in our city is 30,000 yuan; The minimum payment line of serious illness insurance is above 100,000 yuan, and the reimbursement ratio is 55%; 10-200,000 yuan, the reimbursement ratio is 65%; The reimbursement rate for the part above 200,000 yuan is 75%; There is no annual cap for critical illness insurance.
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Source: Huoqiu County Medical Security Bureau Editor: Han Chengjing
Proofreader: Liu Lili Review: Chen Anbang