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Interim Measures for the Protection of Medical Mutual Assistance for On-the-job Employees in Lishui City (Revised Draft)
Edit: admin Source: Lishui Maternal and Child Health Hospital Release time: 2018-01-12 11:45 Read: 0 Times

(Adopted by the third council on December 3, 2015)

Chapter I General Provisions

The first is to carry forward the glorious tradition of unity, friendship, mutual aid and mutual help among the majority of employees, to help hospitalized employees who are sick to reduce the burden of personal medical expenses on basic medical insurance, alleviate the living difficulties of the sick employees, and promote the unity and social stability of the workforce. "Implementation Opinions on Promoting the Employees 'Medical Mutual Assistance Guarantee in Lishui City" (Li Zonggongfa [2013] No. 100) and "Notice on Doing a Good Job in the Municipal-level Coordination of Employees' Medical Mutual Assistance" (Li Zongong Development [2015] 140 (No.) requirements, combined with the actual situation at the municipal level, the Lishui City Workers Medical Mutual Aid Insurance Association research and decision to formulate this method.

Article 2 Lishui City employees medical mutual assistance guarantee work is led by Lishui City Federation of Trade Unions. Lishui City employees medical mutual assistance guarantee will be organized and implemented in accordance with the requirements of overall deployment and step-by-step implementation.

Article 3 "Interim Measures for the Medical Mutual Assistance of Employees in Lishui City (Yunhe County)" (hereinafter referred to as the "Measures"), as supplementary supporting measures for basic medical insurance for Lishui City and Yunhe County employees, must be supplementary Guarantee positioning, unity of rights and obligations, basic balance of income and expenditure, basic principles such as individual voluntary, trade union organization, group insurance, democratic management, and democratic supervision.

Chapter II Mutual Aid

Article 4 Fan Lishui City (including Yunhe County, Lishui Ecological Industry Agglomeration Area) has established unions, enterprises, institutions and "two new" organizations and other units that have participated in the basic medical insurance of Lishui employees in compliance with national laws Incumbent workers of working age may participate in the medical mutual aid protection activities collectively by the union of the unit where they belong. Units that are established separately shall be organized by the unit where they belong; those who participate in the united union shall be united by the unit and participate in the review after the united union. Units with a staff of 100 or less must participate in all, and the number of employees with a staff of 100 or more must not be less than 80%.

Chapter III Security Fees

Article 5 The sources of medical mutual benefit protection for employees include: mutual assistance protection fees paid by member units, government and labor union subsidies, donations from all walks of life, interest and other income, etc., which are used exclusively for the protection of medical mutual assistance for employees.

Article 6 The medical mutual assistance guarantee fund for employees adheres to the principles of overall management, mutual assistance and mutual benefit, and income is determined by expenditure. Unified management means that the medical staff mutual assistance guarantee fee paid by the union of the participating unit is centrally managed and used by the Municipal Employee Medical Mutual Aid Insurance Association; mutual assistance and mutual assistance means that the medical staff mutual assistance guarantee fee paid by the union of the participating unit is unified by the Municipal Medical Worker Mutual Insurance Settlement, non-refundable, roll-over use for the next year; settled by support, that is, the employee's medical mutual assistance protection fee will be fixed for one year according to the annual calculation. The medical insurance for employees is tentatively set at 80 yuan per person. The insured person can only insure one copy during a guarantee period. Enrollment method: One insurance per year.

Article 7 The medical insurance guarantee for employees shall be paid collectively by the unions of the participating units. Workers' medical mutual assistance guarantee funds can be paid by the unit administration and the union. If the unit administration, labor union, and individual employees jointly pay, the specific proportion shall be determined by each unit.

Chapter IV Guarantee Period

Article 8 A period of one-year protection for the hospitalization of medical assistance for employees is one year, that is, from January 1 to December 31 each year. You can continue to participate after a coverage period expires.

Chapter V Safeguard Procedures

Article 9 The medical mutual assistance protection fee for employees shall be paid by a special person designated by the trade union of the participating unit. The unions of the participating units shall, before the end of December of the previous year, meet the requirements of the "Registration Form for Medical Mutual Assistance for On-the-job Employees in Lishui City", the "Registration Form for Medical Mutual Assistance for In-service Employees at Lishui City", Materials such as fees shall be submitted to the Employees Service Center of the Municipal Federation of Trade Unions for examination and relevant insurance procedures.

Chapter VI Guarantee Liability

Article 10 The scope of protection covered by these Measures is paid by the agencies, enterprises, institutions and employees of the "two new" organizations participating in the basic medical insurance at the same level in Lishui City, and paid according to the basic medical insurance certification, designated hospitals for medical insurance, hospitalization, and medical insurance reimbursement. Subsequent payment standards and above shall be borne by the unit and individual in proportion to the expenses, and according to the individual's own medical quota, the mutual assistance payment shall be paid in stages according to the following proportions:

1. The basic fund of the basic medical insurance for inpatient medical expenses shall be paid at 30% of the mutual assistance guarantee fund.

2. After deducting the standard for the payment of the unified fund, after the settlement of social security, the individual's own hospitalization medical expenses are below 5,000 yuan (inclusive), and the mutual assistance guarantee is paid at 40%; for the part of 5,000 to 10,000 yuan (inclusive), the mutual assistance protection is paid at 60%. Gold; for the part above 10,000 yuan, the mutual assistance guarantee fund shall be paid at 70% (the above-mentioned individual medical expenses shall be calculated in stages).

3. The medical expenses incurred by the insured due to the outpatient treatment of special diseases identified by the social insurance agency shall be paid at 45% by the individual at the expense of mutual assistance after the social insurance settlement.

4. Within a guarantee year, the cumulative payment for each mutual assistance guarantee shall not exceed 20,000 yuan.

5. The guarantee responsibility will be terminated upon expiration of the guarantee period.

Article 11 For one of the situations listed below, they shall not be responsible for the payment of medical mutual assistance guarantee funds:

1. Non-insured object;

2. Medical expenses not covered by the medical insurance fund;

3. Medical expenses such as work injury, occupational disease, and female childbirth;

4. Medical expenses for injuries caused by brawls and violations of law;

5. When the coverage period expires, the treatment has not yet ended and the coverage has not been renewed, and the medical expenses exceeding the treatment days in the coverage period;

6. Forging related materials and various deceit and cheating behaviors;

7. Participants voluntarily waived related guarantee benefits in writing.

Chapter VII Guaranteed Benefits

Article 12 The following materials shall be provided to apply for receiving the mutual medical insurance for hospitalization of employees:

1. "Application Form for Medical Mutual Aid Benefit Payment for On-the-job Employees in Lishui City";

2. The original and photocopy of the ID card of the participant;

3. The summary of the discharge from the medical institution, the receipt of hospitalization charges, or the original medical expense reimbursement statement of the medical insurance department (if the original invoice does need to be reimbursed in other departments, a copy of the seal of the insurance unit or other reimbursement department).

Article 13 During the guarantee period, after the insurer has paid for the hospitalization and special outpatient medical expenses of the social security institution, he or she will bring the required materials specified in Article 12 to the office of the Municipal Employees Medical Mutual Aid Insurance Association (City Federation Trade Union Employee Service Center) After handling the approval and settlement procedures of mutual assistance guarantee, the guarantee will pay the mutual assistance guarantee within 7 working days after receiving the complete and complete materials from the participants.

Chapter VIII Consolation Fund System

Article 14: Employees participating in the medical mutual assistance protection of employees who have not died unexpectedly of hospitalization medical expenses during the period of mutual assistance protection shall be paid a commendation fee of 2,000 yuan; employees participating in the medical mutual assistance protection of employees shall be paid a commendation fee of 1,000 yuan for hospitalization; Employees who are seriously ill and severely ill, the medical expenses out-of-pocket (at their own expense and at their own expense) exceed 10,000 yuan and less than 20,000 yuan (inclusive of 20,000 yuan) will be paid a 1,000 yuan condolences; employees who are seriously ill and seriously ill, medical expenses will be partially paid ( At your own expense plus your own expenses) more than 20,000 yuan, 2,000 yuan in consolation money; the above consolation money is limited to one application per person per year.

Chapter 9 Others

Article 15 Employee medical mutual assistance guarantee funds are independently accounted for and used for special purposes. The operation, settlement, and approval are managed by Lishui Employee Medical Mutual Assistance Guarantee Association and subject to audit supervision by the audit department.

Article 16 The Supervisory Board of the Municipal Employees' Medical Mutual Aid Security Association conducts regular and irregular inspections on the operation, settlement and management of the guarantee funds.

Article 17 The development of medical workers' mutual assistance guarantee work serves as an important basis for all kinds of advanced recommendation and evaluation of the work of the municipal-level grassroots trade unions.

Article 18 These Measures shall be implemented as of January 1, 2016.

Article 19 The interpretation of these measures is the responsibility of the Lishui Municipal Employees Medical Mutual Assistance Association.


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