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Decision of Shanghai Municipal People's Government on the Amendment of the "Procedures of Shanghai Municipality on Basic Medical Insurance for Town Employees"

(Promulgated by Decree No.1 of Shanghai Municipal People’s Government on March 28, 2008)

The Municipal People’s Government has decided to make the following amendments to the“Procedures of Shanghai Municipality on Basic Medical Insurance for Town Employees”:

I. Clause 2 of Article 9 is amended to read as follows:

The basic medical insurance premiums paid by the employer-units, besides being charged to the personal medical accounts according to the provisions of Article 11 of these Procedures, shall have the remainder included in the overall fund.

II. Clauses 2 and 3 of Article 11 is amended to read as follows:

About 30% of the basic medical insurance premiums paid by the employer-units shall be charged to the personal medical accounts.

The basic medical insurance premiums paid by the employer-units shall be charged to each personnel medical account according to standards varying with different age brackets.

Three clauses are added to Article 11 as Clauses 4, 5 and 6:

The age brackets for employees on the job are divided as follows:

1. under 34 years of age;

2. between 35 and 44 years of age; and

3. above 45 years of age.

The age brackets for retirees are divided as follows:

1. from retiring age to under 74 years of age; and

2. above 75 years of age.

The SMMIB shall, jointly with relevant departments, study and demonstrate through argumentation the specific standards of changing the basic medical insurance premiums paid by the employer-units to the personal medical accounts and the adjustment thereof, and, after reporting such standards and adjustment to and obtaining the approval from the Municipal People’s Government, promulgate them for implementation.

III. Article 12 is amended to read as follows:

Where any employee should pay the medical insurance premiums but fails to do so, or discontinues enjoying the treatment of basic endowment insurance, the entry of funds as provided under Article 11 of these Procedures shall cease.

IV. Clause 1 of Article 21 is amended to read as follows:

Where employer-units and their employees pay the medical insurance premiums according to provisions, the employees may enjoy the basic medical insurance treatment from the following month of their payment; in case of non-payment of such premiums, the employees shall not enjoy the basic medical insurance treatment.

A clause is added to Article 21 as Clause 5:

For employees who reach the legal retirement age and complete the retiring formalities, the basic medical insurance premiums paid by the employer-units to be charged to their personnel medical accounts for the month when they may draw pensions shall be calculated according to the standard the last month when they were on the job; the disbursement of their medical expenses shall be effected according to the provisions on the basic medical insurance for retirees.

The original Clause 5 is commuted to Clause 6.

V. Article 22 is amended to read as follows:

The expenses incurred in a year by any employees on the job for seeking outpatient and emergency medical treatment or get medicines at designated retail pharmacies, except those provided in Articles 24 and 25 of these Procedures, shall be subtracted from his/her personal medical account. For the insufficient part, such employee himself/herself shall first pay an amount up to the standard of self-payment for outpatient and emergency medical treatment, with the excess part, if any, to be paid according to the following provisions (not including any expenses incurred in getting medicines at designated retail pharmacies):

1. the standard of self-payment for outpatient and emergency medical treatment for those who were born before December 31, 1955 and employed before December 31, 2000 is 1,500 yuan; 70 per cent of the excess medical expenses shall be covered by the additional fund and the remainder borne by the employees on the job themselves.

2. the standard of self-payment for outpatient and emergency medical treatment for those who were born between January 1, 1956 and December 31, 1965 and employed before December 31, 2000 is 1,500 yuan; 60 per cent of the excess medical expenses shall be covered by the additional fund and the remainder borne by the employees on the job themselves.

3. the standard of self-payment for outpatient and emergency medical treatment for those who were born after January 1, 1966 and employed before December 31, 2000 is 1,500 yuan; 50 per cent of the excess medical expenses shall be covered by the additional fund and the remainder borne by the employees on the job themselves.

4. the standard of self-payment for outpatient and emergency medical treatment for those who were newly employed after January 1, 2001 is 1,500 yuan; 50 per cent of the excess medical expenses shall be covered by the additional fund and the remainder borne by the employees on the job themselves.

VI. Article 23 is amended to read as follows:

The expenses incurred in a year by any retiree for seeking outpatient and emergency medical treatment or getting medicines at designated retail pharmacies, except those provided in Articles 24 and 26 of these Procedures, shall be subtracted from his/her personal medical account. For the insufficient part, such retiree himself/herself shall first pay an amount up to the standard of self-payment for outpatient and emergency medical treatment, with the excess part, if any, to be paid according to the following provisions (not including any expenses incurred in getting medicines at designated retail pharmacies):

1. the standard of self-payment for outpatient and emergency medical treatment for those who completed the retiring procedure before December 31, 2000 is 300 yuan, and the additional fund shall cover 90 per cent of the excess medical expenses incurred for outpatient and emergency treatment at Grade I medical institutions, 85 per cent of the excess medical expenses incurred at Grade II medical institutions and 80 per cent of the excess medical expenses incurred at Grade III medical institutions; the remainder shall be borne by the retirees themselves.

2. the standard of self-payment for outpatient and emergency medical treatment for those who were born before December 31, 1955, employed before December 31, 2000, and completed the retiring formalities after January 1, 2001 is 700 yuan, and the additional fund shall cover 85 per cent of the excess medical expenses incurred for outpatient and emergency treatment at Grade I medical institutions, 80 per cent of the excess medical expenses incurred at Grade II medical institutions and 75 per cent of the excess medical expenses incurred at Grade III medical institutions; the remainder shall be borne by the retirees themselves.

3. the standard of self-payment for outpatient and emergency medical treatment for those who were born between January 1, 1956 and December 31, 1965, employed before December 31, 2000 and completed the retiring formalities after January 1, 2001 is 700 yuan, and the additional fund shall cover 70 per cent of the excess medical expenses incurred for outpatient and emergency treatment at Grade I medical institutions, 65 per cent of the excess medical expenses incurred at Grade II medical institutions and 60 per cent of the excess medical expenses incurred at Grade III medical institutions; the remainder shall be borne by the retirees themselves.

4. the standard of self-payment for outpatient and emergency medical treatment for those who were born after January 1, 1966, employed before December 31, 2000 and completed the retiring formalities after January 1, 2001 is 700 yuan, and the additional fund shall cover 55 per cent of the excess medical expenses incurred for outpatient and emergency treatment at Grade I medical institutions, 50 per cent of the excess medical expenses incurred at Grade II medical institutions and 45 per cent of the excess medical expenses incurred at Grade III medical institutions; the remainder shall be borne by the retirees themselves.

5. the standard of self-payment for outpatient and emergency medical treatment for those who were employed after January 1, 2001 and completing the retiring formalities afterwards is 700 yuan, and the additional fund shall cover 55 per cent of the excess medical expenses incurred for outpatient and emergency treatment at Grade I medical institutions, 50 per cent of the excess medical expenses incurred at Grade II medical institutions and 45 per cent of the excess medical expenses incurred at Grade III medical institutions; the remainder shall be borne by the retirees themselves.

VII. Clause 1 of Article 25 is amended to read as follows:

A disbursement threshold is set up for medical expenses incurred by employees on the job for hospitalization or emergency ward observation covered by the overall fund. The disbursement threshold is 1,500 yuan.

VIII. Clause 1 of Article 26 is amended to read as follows:

A disbursement threshold is set up for medical expenses incurred by retirees for hospitalization or emergency ward observation covered by the overall fund. The disbursement threshold for those who retired before December 31, 2000 is 700 yuan, and that for those who retired after January 1, 2001 is 1,200 yuan.

IX. Clause 1 of Article 27 is amended to read as follows:

The disbursement ceiling of the overall fund is 70,000 yuan. The medical expenses above the disbursement threshold incurred by employees for hospitalization or emergency ward observation in a year, and their medical expenses under the disbursement ceiling for outpatient serious diseases or home sickbeds shall be covered by the overall fund in the disbursement proportion as provided in Articles 24, 25 and 26 of these Procedures.

X. Article 33 is amended to read as follows:

For the settlement of medical expenses with the designated medical institutions, the SMMIB may adopt such modes as settlement by advance payment of the gross amount, settlement by service item and settlement by service unit; the part of medical expenses that exceeds the settlement standard shall be shared between the medical insurance fund and the designated medical institutions as prescribed.

XI. Article 35 is amended to read as follows:

The SMMIB and the district/county MIOs shall conduct supervisions and inspections over the medical expense settlement made by the designated medical institutions, retail pharmacies and individual persons. The unit and individual person under inspection shall truthfully provide settlement-related materials such as records, prescriptions and case histories.

A clause is added to Article 35 as Clause 2:

When the frequency of seeking outpatient and emergency medical treatment by an individual person and the expenses thus involved by him/her obviously appear to go beyond the normal situation, the SMMIB may change the mode of expense settlement.

XII. Article 36 is amended to read as follows:

Where any designated medical institutions or retail pharmacies violate the provisions of Article 17, clause 2 of Article 20, Article 30, or Article 34 or other provisions governing the medical insurance, thereby causing a loss to the medical insurance funds, the SMMIB shall order them to make corrections within a time limit, and to retrieve the related medical expenses already disbursed, and may cumulatively give them a warning and impose a fine of not less 3,000 yuan but not more than 100,000 yuan. If the case is serious, their basic medical insurance settlement relationship shall be suspended or their qualification of a designated medical institution or retail pharmacy may be revoked.

A clause is added to Article 36 as Clause 2:

Where relevant sections and the working personnel of any designated medical institutions or retail pharmacies seriously violate the provisions governing the medical insurance, the SMMIB may temporarily suspend their medical insurance expense settlement.

XIII. Article 37 is amended to read as follows:

Where any individual person who violates the provisions of Clause 3 of Article 20 or Article 34 or other provisions governing the medical insurance, thereby causing a loss to the medical insurance fund, the SMMIB shall order him/her to make corrections within a time limit and retrieve the related medical expenses already disbursed, and may cumulatively give him/her a warning and impose a fine of not less than 100 yuan but not more than 10,000 yuan.

XIV. Clause 1 of Article 39 is amended to read as follows:

The administrative and supervisory activities of the overall fund and the additional fund shall follow the relevant provisions on the social insurance fund set by the State and this Municipality. The overall fund and the additional fund shall be brought into the special finance account of social security fund, and managed in a centralized way, kept as independent entities and earmarked for exclusive use, and shall be put under the supervision of the supervisory organs of social security fund set up by the Municipal People’s Government and the departments of finance and auditing.

XV. An article is added as Article 43:

The standard of self-payment range for outpatient and emergency medical treatment, the disbursement threshold of the overall fund and the disbursement ceiling of the overall fund shall be adjusted in good time in the light of actual circumstances. The SMMIB shall, jointly with relevant departments, study and demonstrate through argumentation the specific adjustment scheme, and, after reporting it to and obtaining the approval from the Municipal People’s Government, promulgate it for implementation.

XVI. The original Article 43 is sequentially commuted to Article 44.

This Decision shall become effective on the date of promulgation. The“Procedures of Shanghai Municipality on Basic Medical Insurance for Town Employees”shall be amended accordingly pursuant to this Decision and re-promulgated.

Procedures of Shanghai Municipality on Basic Medical Insurance for Town Employees

(Promulgated by Decree No. 92 of Shanghai Municipal People’s Government on October 20, 2000 and amended in accordance with the“Decision of Shanghai Municipal People’s Government on the Amendment of the‘Procedures of Shanghai Municipality on Basic Medical Insurance for Town Employees’”promulgated by Decree No. 1 of Shanghai Municipal People’s Government on March 28, 2008)

Chapter I General Provisions

Article 1 (Purpose and Basis)

In order to ensure the employees’demands for basic medical treatment, these Procedures are formulated in accordance with the“Implementation Scheme of Shanghai Municipality for Carrying out the‘Decision of the State Council Regarding the Establishment of Basic Medical Insurance System for Town Employees’”.

Article 2 (Scope of Application)

These Procedures apply to the basic medical insurance and its related activities of urban enterprises, organs, institutions, mass organizations, and non-governmental and non-profit units (hereinafter jointly referred to as employer-units) and their employees within the area of this Municipality.

The employees referred to in these Procedures include employees on the job, retirees and other persons taking out insurance.

Article 3 (Administrative Departments)

Shanghai Municipal Medical Insurance Bureau (hereinafter referred to as SMMIB) is the administrative department of the basic medical insurance of this Municipality, responsible for the unified administration of the basic medical insurance of this Municipality. The medical insurance offices of districts and counties (hereinafter referred to as district/county MIO) take charge of the administration of basic medical insurance within their respective jurisdiction.

The municipal departments of public health, labor security, finance, auditing, pharmaceutical product supervision, and civil affairs shall, according to their respective duties, cooperate in their efforts to do well in the basic medical insurance administration.

The social insurance organizations of this Municipality shall take charge of the collection of medical insurance premiums.

Shanghai Municipal Medical Insurance Affairs Administration Center (hereinafter referred to as SMMIC) is the organization of this Municipality that handles medical insurance, responsible for the settlement and appropriation of medical expenses and the administration of personal accounts of basic medical insurance (hereinafter referred to as personal medical accounts).

Chapter II Registration and Payment

Article 4 (Registration Formalities)

The employer-units shall, according to the provisions of SMMIB, go through the registration formalities for basic medical insurance with the designated social insurance agency; newly-established employer-units shall go through the registration formalities for basic medical insurance within 30 days from their set-up date.

In case of lawful termination of employer-units or alteration of registration matters for basic medical insurance, the employer-units shall go through the cancellation or alteration registration formalities with the original registering agency with 30 days from the date when relevant matters occur.

The social insurance agency, when processing the formalities provided in the previous two Clauses of this Article, shall conduct examination as required by the SMMIB and report timely the registration, alteration registration or cancellation registration of employer-units to the SMMIB.

Article 5 (Calculation and Payment Proportion of Employees’Payment Base)

The payment base of an employee on the job is his or her average monthly salaries of the previous year. If his or her average monthly salaries of the previous year exceed 300% of this Municipality’s average monthly salaries of the employees on the job in the previous year, the excess part is not included in the payment base; if falling under 60% of this Municipality’s average monthly salaries of the employees on the job in the previous year, the 60% of the average monthly salaries of this Municipality’s employees on the job in the previous year is taken as the payment base.

The employee on the job shall pay 2% of his or her payment base as the basic medical insurance premium. Retirees are not required to pay the basic medical insurance premiums.

Article 6 (Calculation and Payment Proportion of Employer-Units’Payment Base)

The payment base of an employer-unit is the sum of payment bases of its employees.

The employer-unit shall pay 10 per cent of its payment base as the basic medical insurance premium, and pay 2 per cent of its payment base as the local additional medical insurance premium.

Article 7 (Entry of Medical Insurance Premium)

The entry of medical insurance premiums paid by employer-units shall be made according to regulations of the finance department.

Article 8 (Payment Administration)

The payment amount calculation and payment procedure of employer-units and employees on the job, and the settlement of disputes about payment shall follow the relevant provisions of social insurance premium payment administration.

Chapter III Personal Medical Accounts, Overall Fund and Additional Fund

Article 9 (Basic Medical Insurance Fund)

The basic medical insurance fund consists of the overall fund and personal medical accounts.

Article 10 (Set-up of Personal Medical Accounts)

The SMMIC shall set up personal medical accounts for employees after the employer-units have gone through the medical insurance registration formalities and paid medical insurance premiums according to provisions.

Article 11 (Funds Charged to Personal Medical Accounts)

The basic medical insurance premiums paid by employees on the job shall be charged entirely to their personal medical accounts.

About 30% of the basic medical insurance premiums paid by the employer-units shall be charged to the personal medical accounts.

The basic medical insurance premiums paid by the employer-units shall be charged to each personnel medical account according to standards varying with different age brackets.

The age brackets for employees on the job are divided as follows:

1. under 34 years of age;

2. between 35 and 44 years of age; and

3. above 45 years of age.

The age brackets for retirees are divided as follows:

1. from retiring age to under 74 years of age; and

2. above 75 years of age.

Article 12 (Funds Stopped From Going to Personal Medical Accounts)

Article 13 (Use and Accrued Interest of Personal Medical Account Funds)

Personal medical account funds belong to the individual person. They may be settled and transferred for cross-year use and inherited according to laws.

Personal medical account funds are divided into the funds entered in the current year and the balance funds in the past years.

The year-end funds of personal medical accounts shall carry interest according to relevant provisions and have the interest charged to personal medical accounts.

Article 14 (Inquiry About Personal Medical Account Funds)

Employees may inquire about the entry and outlay of their personal medical account funds. The SMMIB, district/county MIO and SMMIC shall offer convenience for employees to inquire.

Article 15 (Additional Fund)

The local additional medical insurance premiums paid by the employer-units shall be taken entirely into the local additional medical insurance fund (hereinafter referred to as additional fund).

Chapter IV Employees Seeking Medical Treatment and Offer of Medical Services

Article 16 (Definitions of Designated Medical Institutions and Designated Retail Pharmacies)

Designated medical institutions referred to in these Procedures mean the medical institutions that, upon approval by public health administrative departments, have obtained practicing licenses and, upon examination by the SMMIB, obtained permission to establish the basic medical insurance settlement relations.

Designated retail pharmacies referred to in these Procedures mean medicines retailing businesses that, upon approval by medicines supervisory and administrative departments, have obtained business qualification and, upon examination by the SMMIB, obtained permission to establish the basic medical insurance settlement relations.

Article 17 (Service Requirements for Designated Medical Institutions and Designated Retail Pharmacies)

Designated medical institutions and retail pharmacies shall offer services to employees and apply for the settlement of medical expenses according to diagnostic and treatment items, medical service facilities, limits of medication administered, and payment standards covered by the basic medical insurance.

Article 18 (Diagnostic and Treatment Items, Medical Service Facilities, Limits of Medicines Administered, and Payment Standards)

The provisions concerning diagnostic and treatment items, medical service facilities, limits of medicines administered and payment standards covered by this Municipality’s basic medical insurance shall be formulated by the SMMIB jointly with relevant departments according to the State’s provisions.

Article 19 (Employees Seeking Medical Treatment and Getting Medicines)

Employees may go to the designated medical institutions in the city area for medical treatment.

Employees may get medicines at designated medical institutions and may also get medicines at designated retail pharmacies according to provisions.

Employees who work or reside or have emergency treatment out of Shanghai may seek medical treatment in medical institutions of the locality.

Article 20 (Certificates of Medical Insurance)

Employees, when seeking medical treatment in this Municipality’s designated medical institutions or getting medicines at designated retail pharmacies, shall produce their medical insurance certificates.

The designated medical institutions or retail pharmacies shall check the employees’medical insurance certificates.

No one is allowed to falsely use, forge, alter or lend medical insurance certificates.

Chapter V Disbursement of Medical Expenses

Article 21 (Conditions for Employees to Enjoy Basic Medical Insurance Treatment)

If the employer-units apply for delayed payment of medical insurance premiums, their employees do not discontinue enjoying the basic medical insurance treatment during the approved period of delayed payment.

If the employer-units and their employees fail to pay medical insurance premiums that should have been paid, the medical insurance premiums shall be fully repaid before the employees can continue enjoying the basic medical insurance treatment.

If the employer-units’and their employees’accumulated payment years of medical insurance premiums (including those regarded as payment years) exceed 15 years, the employees may enjoy the basic medical insurance treatment after retirement. The calculation of those regarded as payment years shall be provided separately by the SMMIB.

Retirees who have enjoyed the basic medical insurance treatment according to relevant provisions before the implementation of these Procedures shall not be subjected to the provision of this Article.

Article 22 (Outpatient and Emergency Medical Treatment Expenses of Employees on the Job)

The expenses incurred in a year by any employee on the job for seeking outpatient and emergency medical treatment or getting medicines at designated retail pharmacies, except those provided in Articles 24 and 25 of these Procedures, shall be subtracted from his/her personal medical account. For the insufficient part, such employee himself/herself shall first pay an amount up to the standard of self-payment for outpatient and emergency medical treatment, with the excess part, if any, to be paid according to the following provisions (not including any expenses incurred in getting medicines at designated retail pharmacies):

Article 23 (Outpatient and Emergency Medical Treatment Expenses of Retirees)

Article 24 (Medical Expenses of Outpatient Severe Diseases and Home Sickbeds)

Of the medical expenses incurred when the employees undergo severe uremic dialysis, malignant tumor chemotherapy and radiotherapy (hereinafter jointly referred to as outpatient severe disease treatment) at outpatient departments, 85 per cent shall be covered by the overall fund for employees on the job, and 92 per cent for the retirees. The remainder shall be subtracted from the personal medical account balance funds of the past years with any shortages borne by the employees themselves.

Of the medical expenses incurred by employees for home sickbeds, 80 per cent shall be covered by the overall fund; the remainder shall be subtracted from their personal medical account balance funds of the past years with shortages borne by the employees themselves.

Article 25 (Medical Expenses of Hospitalization and Emergency Ward Observation of Employees on the Job)

Of the accumulated medical expenses incurred by employees on the job for hospitalization or emergency ward observation in a year, 85 per cent of the amount that exceeds the threshold shall be covered by the overall fund.

Medical expenses incurred by employees on the job that are under the disbursement threshold and the remainder of medical expenses not covered by the overall fund shall be subtracted from their personal medical account balance funds of the past years with any shortages borne by employees on the job themselves.

Article 26 (Retirees’Medical Expenses of Hospitalization and Emergency Ward Observation)

Of the accumulated medical expenses incurred by the retiree’s hospitalization or emergency ward observation in a year, 92 per cent of the amount that exceeds the disbursement threshold shall be covered by the overall fund.

Retirees’medical expenses that are under the threshold and the remainder of medical expenses not covered by the overall fund shall be subtracted from their personal medical account balance funds of the past years with any shortages borne by the retiree themselves.

Article 27 (Disbursement Ceiling of the Overall Fund and the Expenses Beyond that Limit)

The disbursement ceiling of the overall fund is 70,000 yuan. The medical expenses above the disbursement threshold incurred by employees for hospitalization or emergency ward observation in a year, and their medical expenses under the disbursement ceiling for outpatient severe diseases or home sickbeds shall be covered by the overall fund in the disbursement proportion as provided in Articles 24, 25 and 26 of these Procedures.

Of the medical expenses above the disbursement ceiling of the overall fund, 80 per cent shall be covered by the additional fund, and the remainder shall be borne by employees themselves.

Article 28 (Disbursement of Medical Expenses of Certain Special Diseases)

All the medical expenses incurred by employees’outpatient and emergency treatment, hospitalization, emergency ward observation caused by Class A infectious diseases, family planning operations and their sequels in compliance with the basic medical insurance provisions shall be covered by the overall fund.

If the medical expenses incurred by the employee’s hospitalization or emergency ward observation caused by industrial injuries or occupational diseases exceed the disbursement threshold of the overall fund, 50 per cent of the excess shall be covered by the overall fund, and the remainder and related medical expenses of outpatient and emergency treatment shall be borne by the employer-units according to relevant provisions set by the State and this Municipality.

Article 29 (Cases of No Disbursement)

In any of the following cases, no disbursement is made from the overall fund, the additional fund or personal medical accounts:

1. Any medical expenses incurred when an employee seeks medical treatment at non-designated medical institutions, or gets medicine at non-designated retail pharmacies;

2. Any medical expenses incurred out of compliance with the diagnostic and treatment items, medical service facilities, limits of medicine administered and disbursement standards covered by the basic medical insurance when the employees seek medical treatment and get medicines;

3. Any medical expenses incurred by an employee’s suicide, self-mutilation, fight, drug addiction, medical negligence or traffic accidents; or

4. Other cases provided by the State and this Municipality.

Chapter VI Settlement of Medical Expenses

Article 30 (Entry of Medical Expenses and Deduction by Transfer Through Accounts)

Medical expenses incurred in compliance with the medical insurance provisions when employees seek medical treatment and get medicines shall be handled by presentation of the employee’s medical insurance certificates according to the following provisions:

1. The designated medical institutions shall faithfully keep accounts of those to be covered by the overall fund and the additional fund; and

2. The designated medical institutions or designated retail pharmacies shall deduct those to be subtracted from personal medical account funds from the employee’s personal medical accounts, and shall collect from the employees any shortages of their personal medical account funds.

Designated medical institutions and retail pharmacies shall collect from the employees any medical expenses incurred out of compliance with the basic medical insurance provisions when the employees seek medical treatment or get medicines.

Article 31 (Settlement and Report of Medical Expenses)

The designated medical institutions and retail pharmacies shall settle the medical expenses deducted from the employee’s personal medical accounts with the designated district/county MIO every month.

The designated medical institutions shall settle the for-the-account medical expenses to be covered by the overall fund and the additional fund with the designated district/county MIO every month.

The employees shall settle their medical expenses incurred according to the provision in Article 19 Clause 3 of these Procedures and allowed to be met by the overall fund, the additional fund or personal medical accounts with the designated district/county MIO by presentation of their medical insurance certificates.

Article 32 (Verification and Appropriation of Medical Expenses)

The district/county MIO shall preliminarily examine the medical expenses for settlement within 10 workdays from receiving the settlement application, and report the preliminary examination opinions to the SMMIB.

The SMMIB shall, within 10 workdays from receiving the preliminary examination opinions of the district/county MIO, make the examination decision of approved, delayed or refused disbursement. The SMMIB shall, within 90 days from making the decision of delayed disbursement, make another decision of approved or refused disbursement and notify the correlative units.

The SMMIC shall, within 7 workdays from the approval date, appropriate the medical expenses approved by the SMMIB from the medical insurance fund expending accounts; the medical expenses whose disbursement is refused by the SMMIB shall be borne by the designated medical institutions, retail pharmacies or the employees themselves.

Article 33 (Settlement Mode of Medical Expenses)

Article 34 (Prohibitive Acts in Application for Settlement)

The designated medical institutions, retail pharmacies or individual persons shall not settle medical expenses by deviant means of forging or falsifying accounts, materials, outpatient and emergency prescriptions, and medical expenses bills.

Article 35 (Supervision and Inspection)

Chapter VII Legal Liability

Article 36 (Legal Liability for Wrongful Acts of Designated Medical Institutions and Retail Pharmacies)

Article 37 (Legal Liability of Wrongful Acts of Individual Persons)

Where any individual person who violates the provisions of Clause 3 of Article 22 or Article 34 or other provisions governing the medical insurance, thereby causing a loss to the medical insurance fund, the SMMIB shall order him/her to make corrections within a time limit and retrieve the related medical expenses already disbursed, and may cumulatively give him/her a warning and impose a fine of not less than 100 yuan but not more than 10,000 yuan.

Article 38 (Legal Liability for Wrongful Acts of Medical Insurance Administrative Departments)

If the staff of medical insurance administrative departments and SMMIC abuse powers, engage in malpractice for selfish ends and commit dereliction of duties, thereby causing a loss to the medical insurance fund, the SMMIB shall retrieve the lost medical insurance fund. If the wrongful act constitutes a crime, the wrongdoer shall be investigated into for criminal liability. If the wrongful act is not serious enough to constitute a crime, the wrongdoer shall be given administrative punishments according to law.

Chapter VIII Supplementary Provisions

Article 39 (Administration and Supervision of Medical Insurance Fund)

The annual budget and final accounts of the overall fund and the additional fund shall be prepared by the SMMIB jointly with the municipal public finance bureau and, upon approval by the Municipal People’s Government, put into effect.

Article 40 (Basic Medical Insurance of Other Personnel)

The specific provisions of basic medical insurance for this Municipality’s proprietors and the practitioners of urban self-employed workers and the professional persons shall be formulated separately.

The basic medical insurance of the unemployed during the period of claiming unemployment insurance benefits shall follow the relevant provisions set by the State and this Municipality.

Article 41 (Special Provision for Persons with Extended Work Years)

Persons who reach the legal retirement age but, according to the State provisions, have their work years extended and temporarily do not go through the retiring formalities shall be subject to the provisions of basic medical insurance of the employees on the job. After completing the retiring formalities, they shall be subject to the basic medical insurance for the retiree in the same age brackets.

Article 42 (Transitional Period of Socialized Administration)

A period of one year beginning from the implementation date of these Procedures is the transitional period of this Municipality’s socialized administration of the basic medical insurance. The specific operational procedures shall be formulated separately.

Article 43 (Adjustment of the Standard of Self-payment Range for Outpatient and Emergency Medical Treatment, the Disbursement Threshold of the Overall Fund and the Disbursement Ceiling of the Overall Fund)

Article 44 (Effective Date)