Procedures of Shanghai Municipality on the Supervisory Administration of Basic Medical Insurance were adopted at the 80^th Routine Meeting of the Municipal People’s Government on March 30, 2020, and are hereby promulgated. They shall be effective as of June 1, 2020.

Acting Mayor: Gong Zheng

April 13, 2020

 

Procedures of Shanghai Municipality on the Supervisory

Administration of Basic Medical Insurance

(Promulgated by Decree No. 31 of Shanghai Municipal People’s Government on April 13, 2020)

 

Article 1 (Purposes and Basis)

With a view to assuring the basic medical needs of the insured, standardizing and strengthening the supervisory administration of the basic medical insurance, and securing the medical insurance fund, the Procedures of Shanghai Municipality on the Supervisory Administration of Basic Medical Insurance are formulated based on the Social Insurance Law of the People’s Republic of China and other relevant laws and rules, and in the light of the actual circumstances of this Municipality.

Article 2 (Application Scope)

These Procedures apply to the supervisory administration over the designated medical institutions of basic medical insurance (hereinafter referred to as the designated medical institutions), designated pharmacies of basic medical insurance (hereinafter referred to as the designated pharmacies), and the individuals in observing the regulations on basic medical insurance in this Municipality.

The basic medical insurance mentioned in these Procedures refers to the urban employee basic medical insurance and urban and rural resident basic medical insurance.

The supervisory administration over the implementation of maternity insurance, and of the long-term care insurance in this Municipality that use basic medical insurance fund as their financing channel is subject to the relevant provisions of these Procedures.

Article 3 (Department of Medical Insurance Supervisory Administration)

The Municipal Healthcare Security Administration is the competent administrative department in charge of the basic medical insurance in this Municipality and responsible for the supervisory administration over the basic medical insurance across this Municipality. The district healthcare security administrations are responsible for the supervision over the basic medical insurance in their respective administrative areas.

The municipal medical insurance supervision institution shall, in the name of the Municipal Healthcare Security Administration, specifically put in practice the administrative law enforcement including supervision and inspection of the basic medical insurance, and strengthen the supervision and inspection forces in line with the necessity of supervision and administration.

The departments of development & reform, health, market regulation, medical products administration, finance, audit, public security, civil affairs, human resources and social security shall, within their respective functions and duties, cooperate to support the supervisory administration of basic medical insurance.

Article 4 (Information System of Medical Insurance)

The Municipal Healthcare Security Administration shall establish and improve the information system of the practicing physicians in designated medical institutions and the system of basic medical insurance expenses settlement, carry out real-time monitoring of the basic medical insurance expenses arising from the provision of medical services by designated medical institutions and practicing physicians, regulate the medical services of the practicing physicians in the designated medical institutions, and implement a rate-based management over the practicing physicians whose violations are found during supervision and administration.

The designated medical institutions and the designated pharmacies shall, in accordance with this Municipality’s requirements on networking settlement of basic medical insurance expenses, install necessary networking equipment, observe the information technology standards and relevant information security regulations for basic medical insurance, and in a timely and precise manner upload the relevant information on the basic medical insurance expenses settlement.

Article 5 (Service Agreements)

The Municipal Medical Insurance Administration Center is the institution specifically operating the basic medical insurance, and signs service agreements with the designated medical institutions, designated pharmacies and designated assessment institutions of the long-term care insurance (hereinafter referred to as the designated assessment institutions) and designated long-term care providers (hereinafter referred to as the designated care providers) in accordance with relevant regulations of the State and this Municipality.

The Municipal Medical Insurance Administration Center may suspend or rescind the service agreements with the designated medical institutions, pharmacies, assessment institutions or care providers if they have any violation of these Procedures or the terms of the service agreements.

Article 6 (Internal Management)

The designated medical institutions and the designated pharmacies shall observe the regulations of the State and this Municipality on basic medical insurance and the service agreements, and establish and prefect a sound internal management system for basic medical insurance.

The Grade III and II medical institutions within the scope of designated medical institutions shall set up departments in charge of basic medical insurance, and appoint necessary management staff; other medical institutions shall have full-time (or part-time) staff to manage basic medical insurance.

The designated pharmacies shall have full-time (or part-time) staff to manage basic medical insurance.

Article 7 (Management of Medical Insurance Premiums)

The designated medical institutions shall execute the relevant provisions of this Municipality on the budget management of basic medical insurance expenses payment and the total prepayment management, ensure the basic needs of the insured for medical treatments, and regulate the use of the basic medical insurance fund.

Article 8 (Requirements for Services Provided by Designated Medical Institutions)

The designated medical institutions shall reasonably select the medical treatments and determine the medication in accordance with the state of illness of the insured and the provisions of the basic medical insurance regarding the medical treatments, medical service facilities, prescription management and scope of medication.

The designated medical institutions providing medical services to the insured shall comply with the provisions of the basic medical insurance concerning medical treatments, medical service facilities, scope of medication, price management and payment tariff, and provide medical expense settlement receipts to the insured.

The designated medical institutions shall provide direct and instant settlement of the medical expenses for the non-resident insured persons according to relevant provisions of the State and this Municipality.

Article 9 (Requirements for Services Provided by Designated Pharmacies)

The designated pharmacies selling prescription and non-prescription medicines to the insured shall not accept payments settled by the basic medical insurance if the prescription does not meet the provisions of basic medical insurance on medication; the non-prescription medicines sold to the insured shall not violate the provisions of the basic medical insurance on the scope, variety and quantity of medication.

The designated pharmacies providing medication dispensing services shall observe relevant provisions on price management and payment tariff, and offer relevant settlement receipts to the insured.

Article 10 (Real-time Monitoring)

The municipal medical insurance supervision institution shall monitor in real time the frequency of the insured seeking out-patient or emergency medical consultations in a month and the basic medical insurance expenses incurred, and the basic medical insurance expenses arising from the medication dispensing of the designated pharmacies to the insured in a month. If the monitoring indicates that the medical treatment and medication dispensing of the insured exceeds the prescribed scope, the district healthcare security administrations and the municipal medical insurance supervision institution may temporarily change the accounting and settlement method of the basic medical insurance expenses for outpatient or emergency consultations or medication dispensing of the insured.

If measures are taken to temporarily change the method of accounting and settlement method of basic medical insurance expenses, the district healthcare security administrations and the municipal medical insurance supervision institution shall notify the insured and promptly review their medical consultations and medication dispensing. The insured shall cooperate in the review, and provide information and materials as required.

If, after review, no violation of the basic medical insurance regulations by the insured is found, the district healthcare security administrations and the municipal medical insurance supervision institution shall resume the accounting and settlement of basic medical insurance on the day when the review and inspection are completed.

If, after review, the insured are found to have violated the provisions of the basic medical insurance, the Municipal or district healthcare security administrations shall deal with them in accordance with the provisions of Paragraph 2 of Article 15 or Article 19 of these Procedures.

Article 11 (Supervision and Inspection Measures)

When carrying out supervision and inspection, the district healthcare security administrations and the municipal medical insurance supervision institution may take the following measures:

1. collecting relevant information and materials by means of interrogation, audio recording, video recording, photo-taking or photocopying, and registering and safekeeping them in advance in the event that they may be lost or transferred;

2. extracting data from the basic health insurance-related information system and requesting explanations and clarifications of the persons subject to inspection on the suspicious data; and

3. conducting warning interviews with the heads of relevant institutions and those directly responsible.

The persons subject to inspection shall provide materials and data related to the supervision and inspection, as well as explanations and clarifications as required by the district healthcare security administrations and the municipal medical insurance supervision institution.

The municipal and district healthcare security administrations shall innovate their supervision and administration methods, promote the application of information technology in the supervisory administration of the basic medical insurance funds, achieve full coverage of supervision and administration, and enhance the effectiveness of supervision and administration.

Article 12 (Related Matters to Be Entrusted)

When carrying out supervision and inspection, the district healthcare security administrations and the municipal medical insurance supervision institution may appoint third-party organizations and relevant experts to audit or examine the use of the basic medical insurance fund, and verify and advise on matters related to basic medical insurance.

Article 13 (Related Requirements for Long-term Care Insurance)

If the eligible insured persons apply for unified needs assessment for elderly care, the designated assessment institutions shall, in accordance with the assessment standards and procedures of this Municipality, conduct a comprehensive assessment based on the applicant’s self-care ability and disease to determine the assessment grade.

The designated care providers shall offer services for the eligible applicants after assessment in accordance with relevant service contents and regulations.

Article 14 (Presentation and Verification of Relevant Social Insurance Certificate)

The insured, when engaging in registration, outpatient, examination, treatment, dispensing, hospitalization, or settlement at a designated medical institution, or accepting dispensed medicines in a designated pharmacy, or applying for unified needs assessment for elderly care, enjoying care services and settling relevant expenses, shall present their basic medical insurance certificates including social security cards.

The insured shall safekeep their own basic medical insurance certificates including social security cards, and not lend them to others for use. The loss of funds in their personal accounts caused by the failure to report the loss of the social security card and other basic medical insurance certificates in time shall be self-borne.

The designated medical institutions, pharmacies, assessment institutions and care providers shall verify the social insurance certificates including social security cards of the insured in the course of service provision.

Article 15 (Legal Liability for Defrauding Basic Medical Insurance Fund)

If a designated medical institution or a designated pharmacy uses fraudulent or falsified documents or other means to defraud the basic medical insurance fund, the municipal or district healthcare security administrations shall order the refund, and impose a fine of not less than two times but not more than five times the expenses settled through the basic medical insurance fund.

If the insured or other people use fraudulent or falsified documents or other means to defraud the basic medical insurance for benefits, the municipal or district healthcare administrations shall order the refund of payment by the basic medical insurance fund, and impose a fine of not less than two times but not more than five times the expenses settled through the basic medical insurance fund.

Article 16 (Legal Liability of Designated Medical Institutions and Designated Pharmacies for Violations of Basic Medical Insurance Regulations)

For one of the following acts committed by a designated medical institution or a designated pharmacy, the municipal or district healthcare security administrations shall order corrections and the refund of payment by the basic medical insurance fund, and may issue a warning or impose a fine of not less than 3,000 yuan but not more than 30,000 yuan; if the case is serious, a fine of not less than 30,000 yuan but not more than 100,000 yuan shall be imposed, and the service agreements may be suspended:

1. failing to verify the basic medical insurance certificates, and settling the basic medical insurance expenses for persons violating the regulations on the use of basic medical insurance certificates during consultations or medication dispensing;

2. settling the basic medical insurance expenses through charging the insured with repetitive fee collection, split-up collection, over-standard collection, or collection with self-set standards;

3. settling the basic medical insurance expenses that violate relevant provisions of the basic medical insurance by using the medicines, diagnosis and treatment, medical consumables, and medical service facilities within the scope of the basic medical insurance or of the agreed service as other medicines, diagnosis and treatment, medical consumables, and medical service facilities within the said scope, or by providing invoices, bills, prescriptions and other records that do not correspond to the actual medical activities;

4. settling the basic medical insurance expenses incurred from using medicines, diagnostic and treatment items and medical consumables with special restrictions which violates the provisions of the basic medical insurance;

5. settling the basic medical insurance expenses incurred from allowing unregistered physicians to engage in medical services or the registered physicians to engage in medical services beyond their registered scope of practice or place of practice;

6. settling the basic medical insurance expenses incurred from conducting medical activities beyond the approved and registered medical service scope;

7. settling the basic medical insurance expenses that do not comply with the ratio of expenses set by the provisions of the basic medical insurance;

8. settling with the insured the basic medical insurance expenses that ought to be self-borne to be paid by the basic medical insurance fund;

9. requesting the insured to pay for the expenses that should be covered by the basic medical insurance fund; or

10. settling the basic medical insurance expenses in other ways that impair the basic medical insurance fund.

Article 17 (Legal Liability of Designated Medical Institutions and Designated Pharmacies for Serious Violations of Basic Medical Insurance Regulations)

For one of the following acts committed by a designated medical institution or a designated pharmacy, the municipal or district healthcare security administrations shall order corrections and the refund of payment by the basic medical insurance fund, impose a fine of not less than 30,000 yuan but not more than 100,000 yuan, and may suspend or terminate service agreements; if the case is serious, a fine of not less than 100,000 yuan but not more than 300,000 yuan shall be imposed, and the service agreements shall be suspended or terminated:

1. settling the basic medical insurance expenses if the medicines, diagnostic and treatment items, medical consumables, and medical service facilities beyond the scope of the basic medical insurance or of the agreed services are used as medicines, diagnostic and treatment items, medical consumables, and medical service facilities within the said scope;

2. settling the basic medical insurance expenses if the daily necessities, health invigorants and other non-pharmaceutical items are used as the medicines covered by the basic medical insurance;

3. settling the basic medical insurance expenses for the insured by providing medical services through repeated registrations, repeated or no-disease-index lab tests, checkups, treatment, split-up prescription, or hospitalization;

4. settling the basic medical insurance expenses if the insured are dispensed with no-disease-index, over-coursed treatment, over-dosage or repetitive medicines, or through split-up prescription or alterations that violate the provisions of the basic medical insurance on medicine scope and medicine varieties;

5. settling the basic medical insurance expenses for the persons or organizations that are not eligible for the basic medical insurance settlement through letting out or subcontracting medical service sections;

6. settling the basic medical insurance expenses through unauthorized networking or unauthorized networking with non-designated medical institutions or pharmacies without signing or altering service agreements in accordance with relevant provisions;

7. issuing birth certificates or medical history documents for the purpose of  fraudulently or unreasonably obtaining maternity subsistence allowance and maternity expense subsidies; or

8. settling the basic medical insurance expenses in other ways that seriously impair the basic medical insurance fund.

Article 18 (Legal Liability for Violations of Relevant Provisions on Long-term Care Insurance)

Where the designated assessment institutions or care providers, in violation of the relevant provisions on long-term care insurance assessment, care services and fee settlement, settle the expenses through the long-term care insurance fund, the municipal or district healthcare security administrations shall order corrections and the refund of payment by the basic medical insurance fund, issue a warning or impose a fine of not less than 3,000 yuan but not more than 30,000 yuan, and may suspend or terminate service agreements; if the case is serious, a fine of not less than 30,000 yuan but not more than 100,000 yuan shall be imposed, and the service agreements may be suspended or rescinded.

Article 19 (Legal Liability for Personal Violations)

For one of the following acts committed by the insured or other persons, the municipal or district healthcare security administrations shall order the refund of payment by the basic medical insurance fund, and may issue a warning or impose a fine of not less than 100 yuan but not more than 2,000 yuan; if the case is serious, a fine of not less than 2,000 yuan but not more than 10,000 yuan shall be imposed, and measures may also be taken to alter the way of accounting and settlement of the basic medical insurance for 1 to 6 months:

1. lending their basic medical insurance certificates for others’ use, or settling the basic medical insurance expenses through compensated transfers of diagnosis documents, treatment documents or documents of treatment;

2. selling off medicines reimbursed by the basic medical insurance;

3. settling the basic medical insurance expenses through repeated consultations for excessive medicine dispensing in different designated medical institutions or in different medical sections of the same designated medical institution;

4. providing false information or documents to fraudulently obtain long-term care insurance benefits when applying for or receiving long-term care insurance assessment or care services;

5. settling the basic medical insurance expenses in other ways that impair the basic medical insurance fund.

When the insured apply for comprehensive basic medical insurance cost reduction, the self-paid medical expenses of the insured incurred from the acts specified in the preceding paragraphs shall not be included in the calculation of the annual self-paid medical expenses.

Article 20 (Administrative Punishment Standards)

The Municipal Healthcare Security Administration shall, in accordance with the regulations of the State and this Municipality and in conjunction with basic medical insurance supervision and administration practice, refine and quantify the amount and multiplier of fines specifically applicable to violations of the laws and regulations, and set benchmarks for discretion.

Article 21 (Measures to Handle Other Violations of the Basic Medical Insurance Provisions)

Where the relevant sections or staff of designated hospitals and designated pharmacies have severely violated the provisions of the basic medical insurance, the Municipal Healthcare Security Administration may temporarily suspend their basic medical insurance settlement.

Article 22 (Social Credit Penalty)

The Municipal Healthcare Security Administration shall establish and perfect the medical social credit evaluation system and information disclosure system. The dishonesty information of the designated medical institutions, the designated pharmacies, the designated assessment institutions and the designated care providers and their working staff, and the insured and other persons shall be collected and integrated according to the relevant provisions of the State and this Municipality, and joint penalty shall be imposed according to law.

Article 23 (Case Handover)

The municipal and district healthcare security administrations shall, in the course of investigating and dealing with the acts that violate the law, hand over the cases to the public security departments if the amount of money, the circumstances of violation, and the consequences caused by the violation are suspected of constituting a crime that amounts to criminal liability according to law.

Article 24 (Legal Liability of the Administrative and Supervisory Personnel)

The staff of the basic medical insurance administration and supervision shall, in accordance with the relevant regulations of the State and this Municipality, perform their functions and duties in basic medical insurance administration and supervision; they shall not abuse their power, conduct malpractices for personal gains, or neglect their duties. Those that commit any act that violates relevant regulations shall be punished with administrative sanctions by the municipal and district healthcare security administrations according to law. In the case the working staff’s acts bring about losses to the medical insurance fund, the losses shall be recovered. If the case constitutes a crime, the offender shall be prosecuted for criminal liability as provided by law.

Article 25 (Reference for Implementation)

The supervision and administration of other supplementary insurance including the urban-rural critical disease insurance that uses the basic medical insurance fund as their financing channel shall be conducted in reference to these Procedures.

The supervision and administration of the medical services provided for the insured non-resident by the designated medical institutions in this Municipality and of their medical visits in the designated medical institutions in this Municipality shall be conducted in reference to these Procedures.

Article 26 (Effective Date)

These Procedures shall be effective as of June 1, 2020. Procedures of Shanghai Municipality on the Supervisory Administration of Basic Medical Insurance promulgated on January 30, 2011, shall be simultaneously repealed.