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What are the regulations for the Medical Insurance Standards for Urban Self-employed Professionals, Private Business Owners and their Employees (Personal Insurance Participants)?
(02.21.2008)

Urban self-employed professionals, private business owners and their employees (called "personal insurance participants") and the retired beneficiaries of monthly pensions/annuities (called "retired persons") should open a Individual Medical Account, but all other employed persons who are urban insurance participants should not.

The participants may see doctors in the dedicated medical institutions they select; each participant may select no more than three dedicated medical institutions.

1. For medical expenses incurred in a clinic or through emergency treatment delivered to a participant, a currently employed person shall pay at his/her own cost, and a retired person shall pay with their Individual Medical Account. If the participant cannot meet the incurred expenses, he/she shall pay the deductable of 10% of the city average wage for the previous year in Shanghai. All other medical expenses shall be paid as follows:

(1) In the case of clinical or emergency treatment in a Grade-1 medical institution, the Municipal Medical Insurance Fund shall pay 55% of all expenses, and the participant shall pay the remainder;

(2) in the case of a Grade-2 medical institution, the Fund shall pay 50%, and the participant shall pay the remainder;

(3) in the case of a Grade-3 medical institution, the Fund shall pay 45%, and the participant shall pay the remainder.

2. For expenses that participants incur at a dedicated retail drugstore dispensary, according to the related rules of the medical insurance:

(1) A currently-employed person shall pay fully at their own cost, and

(2) a retired person shall have the expense directly deducted from their personal medical account by the dedicated drugstore and the remainder shall be paid at the participant’s own cost.

3. For expenses that participants incur in a severe uremia dialysis clinic, or through chemical or radiation treatment for malignant tumor(s):

(1) employed persons shall have 85% of the expenses paid by the Municipal Medical Insurance Fund, and the remainder shall be paid at their own cost;

(2) retired persons shall have 92% of the expenses paid by the Municipal Medical Insurance Fund, and the remainder shall be paid with the balance of their personal medical account.

Any outstanding remaining amount of the above treatment shall be paid at the participant’s own cost.

4. For medical expenses that a participant incurs through at-home medical treatment:

(1) Employed persons shall have 80% of the expenses paid by the Municipal Medical Insurance Fund, and the remainder should be paid at their own cost;

(2) retired persons shall have 80% of the expenses paid by their Municipal Medical Insurance Fund, and the remainder should be paid with the balance of their Individual medical account.

Any outstanding remaining amount of the above treatment shall be paid at the participant’s own cost.

5. A deductable, equal to 10% of the city average wage for the previous year in Shanghai, shall be set for the medical expenses that the participants incur through their hospitalization or emergency treatment and shall be paid with the Municipal Medical Insurance Fund.

For medical expenses that employed persons incur through their hospitalization or the emergency treatment in a Medical Insurance Year, 85% of the amount above the deductable shall be paid with the Municipal Medical Insurance Fund, with any remainder to be paid at the participant’s own cost.

For medical expenses that retired pensioners incur through their hospitalization or the emergency treatment in a Medical Insurance Year, 92% of the amount above the deductable shall be paid with the Municipal Medical Insurance Fund, with any remainder to be paid with the balance of their Individual Medical Accounts. Any outstanding remaining amount of the above treatment shall be paid at the participant’s own cost.

If medical expenses that incur during hospitalization, emergency treatment or through at-home medical treatment in a Medical Insurance Year are above the deductable, and if they are more than 4 times the average annual employee salary in the previous year in Shanghai, 80% of the above-standard part shall be paid by the Municipal Medical Insurance Fund and the remaining 20% shall be paid at the participant’s own cost.