(Adopted at the 91st Executive Meeting of the Seventh Shenzhen Municipal People’s Government on September 4, 2023.)
Chapter Ⅰ General Provisions
Article 1 These measures are formulated in accordance with the Social Insurance Law of the People’s Republic of China, theRegulations on Supervision and Administration of the Use of Healthcare Security Funds, and other relevant laws and regulations and in the light of the actual circumstances of Shenzhen Municipality for the purpose of establishing and strengthening the healthcare security system and safeguarding the legitimate rights and interests of basic healthcare security of the insured.
Article 2 The people’s governments shall establish the basic healthcare security system with basic medical insurance as the main body, critical illness insurance as the supplement, and medical assistance as the backstop. A healthcare security system with joint development of basic healthcare security, commercial health insurance, charitable donations, and medical mutual aid shall be strengthened.
Basic medical insurance includes employees’ basic medical insurance and residents’ basic medical insurance.
The employees’ basic medical insurance is classified into two forms, namely, Tier I and Tier II, according to the premiums contribution and the corresponding benefits.
Article 3 These measures shall apply to such activities as fund raising for participation in the medical insurance, fund administration, benefit guarantee, medical treatment service, and supervision and administration within the administrative area of this municipality.
Article 4 The healthcare security system of this municipality shall adhere to the centering on the people’s health and comply with the principles of covering all the people, clear rights and responsibilities, proper guarantee, safety and standardization, and sustainability.
Article 5 The municipal healthcare security administrative department shall take principal charge of the security of healthcare, and the municipal healthcare security agency shall specifically undertake the healthcare security work.
The municipal departments of finance, human resources, health, market supervision and regulation, taxation shall, according to their respective functions and duties, be responsible for the corresponding healthcare security work.
Article 6 The municipal healthcare security administrative department may, in accordance with the revenue and expenditure of the medical insurance fund, make corresponding adjustments to the proportion of contribution, healthcare security benefits, etc., and report the adjustments to the municipal people’s government for approval before implementation.
If there are provisions on the contribution and treatment of medical insurance of the State and Guangdong Province prescribe otherwise, such provisions shall prevail.
Chapter Ⅱ Insurance Financing
Article 7 Employers shall participate in Tier I of employees’ basic medical insurance for their employees with household registration in this municipality, and participate in Tier I or II of employees’ basic medical insurance for their employees without household registration in this municipality. In accordance with relevant provisions of the State and Guangdong Province, Tier II premium rates for employees’ basic medical insurance shall be progressively transitioned to Tier I of employees’ basic medical insurance.
The following personnel shall participate in employees’ basic medical insurance in the following ways:
(1) Flexible-employment personnel shall participate in Tier I of employees’ basic medical insurance;
(2) Personnel shall participate in Tier I of employees’ basic medical insurance during the period of receiving unemployment insurance benefits;
(3) Employees with work-related disability assessed as having Grade I to Grade IV disability and going through the formalities for disability retirement shall participate in Tier I of employees’ basic medical insurance;
(4) Personnel who receive disability allowances and do not contribute the premiums for their employers shall participate in Tier I or II of employees’ basic medical insurance; and
(5) Personnel who are confirmed to be entitled to basic medical insurance treatment of this municipality after retirement when they reach the statutory retirement age shall participate in Tier I or II of employees' basic medical insurance in accordance with relevant provisions of the transfer and continuation of basic medical insurance relationships of the Municipality.
Other entities and personnel prescribed by the State, Guangdong Province and this municipality shall participate in employees’ basic medical insurance in accordance with relevant provisions.
Article 8 For the employee participating in Tier I of employees’ basic medical insurance, the premiums shall be paied monthly in the amount of 8% of the contribution base, among which 6% shall be paid by the employer and 2% by the employee.
For the employee participating in Tier II of employees’ basic medical insurance, the premiums shall be paid monthly in the amount of 2% of the contribution base, among which 1.5% shall be paid by the employer and 0.5% by the employee.
The part that ought to be paid by the employee shall be withheld and remitted by the employer.
The contribution base of the employer shall be the total amount of wage for contribution payment of its employees, and the contribution base of each individual shall be the amount of his/her monthly salary. The contribution base shall set upper and lower limits. If the monthly salary of the employee exceeds 300% of the average monthly salary of the full-caliber urban employees of this municipality for the year before the preceding year, the upper limit shall be determined at 300%; if the monthly salary of the employee is less than 60% of the average monthly salary of the full-caliber urban employees of this municipality for the year before the preceding year, the lower limit shall be determined at 60%.
Article 9 For employees as stipulated in Item (1) of Clause 2 of Article 7 hereof, the contribution base shall be the monthly salary declared by the employee, and the basic medical insurance premiums shall be contributed monthly at the rate of 8% of the contribution base. The contribution base shall be subjeted to upper and lower limits. If the monthly salary declared by the employee exceeds 300% of the monthly average salary of the full-caliber urban employees for the year before the preceding year of this municipality, the upper limit shall be determined at 300%; if the monthly salary declared by the employee is less than 60% of the monthly average salary of the full-caliber urban employees for the year before the preceding year of this municipality, the lower limit shall be determined at 60%.
For employees as stipulated in Item (2) of Clause 2 of Article 7 hereof, the contribution base shall be the monthly average salary of the full-caliber urban employees for the year before the preceding year of this municipality, and the municipal social insurance institution shall monthly contribute employees’ basic medical insurance premiums at the rate of 8% of the contribution base, and the expenses shall be disbursed from the unemployment insurance fund.
For employees as stipulated in Item (3) of Clause 2 of Article 7 hereof, the contribution base shall be the disability allowance for work injury, and the insurance formalities shall be completed by the municipal social insurance institution. The employees’ basic medical insurance premiums shall be monthly contributed at the rate of 8% of the contribution base, among which 6% shall be paid by the work injury insurance fund and 2% by the personnel himself, and the part paid by the personnel himself shall be withheld and paid by the municipal social insurance institution from the issued disability allowance.
For employees as stipulated in Item (4) of Clause 2 of Article 7 hereof, the contribution base shall be between 60% and 300% of the monthly average salary of the full-caliber urban employees for the year before the preceding year of this municipality. For those who participate in Tier I of employees’ basic medical insurance, they shall monthly contribute the employee basic medical insurance premiums at the rate of 8% of the contribution base; for those who participate in Tier II of employees’ basic medical insurance, they shall monthly contribute the employee basic medical insurance premiums at the rate of 2% of the contribution base.
Article 10 For personnel as stipulated in Item (5) of Clause 2 of Article 7 hereof, if the actual contribution period for participating in employees’ basic medical insurance in this municipality is no less than 10 years, and the cumulative contribution period for participating in employees’ basic medical insurance simultaneously complies with relevant provisions of Guangdong Province on transfer and continuation of basic medical insurance relationship, the personnel mentioned above shall cease to contribute premiums and be entitled to employees’ basic medical insurance treatment. Among them, the personnel who retire in 2023 shall have contributed insurance premiums no less than 24 years in accumulative total; the personnel who retire in 2024 shall have contributed insurance premiums no less than 25 years in accumulative total.
The actual contribution period for employees’ basic medical insurance premiums in this municipality shall include the period for participation in Tier I and Tier II of employees’ basic medical insurance. If the transfer is completed in accordance with the provisions of the State, Guangdong Province and this municipality on transfer and continuation of basic medical insurance relationships, the contribution period for the employees’ basic medical insurance premiums outside this municipality shall be included in the cumulative contribution period for computation.
If the contribution period does not comply with the provisions as set forth in Clause 1 of this Article when the insured retires, the insured is required to continue to monthly contribute the employees’ basic medical insurance premiums. The contribution base shall comply with relevant provisions of Guangdong Province on transfer and continuation of basic medical insurance relationship, and shall not be less than 60% of the average monthly salary of the full-caliber urban employees of this municipality for the year before the preceding year. The premium rates for Tier I and Tier II of employees’ basic medical insurance shall be 6% and 2% respectively.
If the insured has reached the statutory retirement age, the confirmation of the place where he/she enjoys basic medical insurance treatment for employees after retirement shall be handled in accordance with relevant provisions of Guangdong Province on transfer and continuation of basic medical insurance relationship.
Article 11 The following personnel may participate in residents’ basic medical insurance:
(1) Residents with household registration of this municipality under 18 years of age, the juveniles and children in primary and secondary schools and kindergartens in this municipality, and full-time students accepting general higher education for academic qualifications at various full-time ordinary institutions of higher education (including privately-run schools) or scientific research institutions in this municipality;
(2) Residents with household registration of this municipality over 18 years of age who do not participate in the employees’ basic medical insurance;
(3) Other personnel prescribed by the State, Guangdong Province and this municipality.
Article 12 The basic medical insurance fund for residents shall be raised in combination of individual contributions and government subsidies. The contribution base for the residents’ basic medical insurance is the monthly disposable income of urban residents of this municipality for the year before the preceding year, and the insured shall monthly contribute the premiums at the rate of 1.8% of the contribution base. Among which, for the personnel stipulated in Item (1) of Clause 1 of Article 11 hereof, 0.6% shall be paid by the personnel himself/herself and 1.2% shall be subsidized by public finance; for the personnel stipulated in Item (2) of Clause 1 of Article 11 hereof, 0.7% shall be paid by the personnel himself/herself and 1.1% shall be subsidized by public finance. Individual contribution standard and government subsidy standard shall not be lower than those prescribed by the State or Guangdong Province.
The personnel stipulated in Item (1) of Clause 1 of Article 11 hereof shall go through the formalities of the residents’ basic medical insurance each September and contribute the premiums on residents’ basic medical insurance for the period from September of the year to August of the next year in a lump sum; if the formalities are completed in other months, the premiums of the rest months shall be contributed in a lump sum since the month of applying. Schools, scientific research institutions, or kindergartens shall uniformly handle the formalities of the residents’ basic medical insurance for students, juveniles, and children.
Article 13 For the personnel eligible to have the medical aid of this municipality, the municipal healthcare security agency shall, in accordance with relevant provisions, provide financial subsidies for individual premiums on the basic medical insurance.
For residents with household registration of this municipality assessed as having Grade I to Grade IV disability, the municipal disabled persons’ federation shall, in accordance with relevant provisions, provide subsidies for individual premiums on the residents’ basic medical insurance.
Article 14 The personnel participating in the employees’ or residents’ basic medical insurance are entitled to critical illness insurance treatment besides the basic medical insurance treatment, and the employers participating in the insurance and the insured do not need to contribute any other primium.
Article 15 Employers and individual contributors shall go through the formalities of social insurance registration, change, and cancellation etc. in accordance with relevant provisions.
Article 16 Forms of the employees’ basic medical insurance which employers have selected for employees in accordance with these Measures shall not be changed within one medical insurance year.
Article 17 The period for which the insured have participated in Tier I of the basic medical insurance before the implementation of these Measures shall be deemed as the period for participation in Tier I of the employees’ basic medical insurance; the period for which the insured have participated in Tier II and III of the basic medical insurance before the implementation of these Measures shall be deemed as the period for participation in Tier II of the employees’ basic medical insurance.
The period for which residents with household registration of this municipality under 18 years of age, the juveniles and children in primary and secondary schools and kindergartens in this municipality, and full-time students accepting higher education for academic qualifications at various full-time ordinary institutions of higher education (including privately-run schools) or scientific research institutions in this municipality have participated in Tier II of the basic medical insurance before the implementation of these Measures shall be deemed as the period for participation in the residents’ basic medical insurance.
Article 18 The basic medical insurance relationship for residents of which the insured enjoying basic medical insurance treatment shall be suspended and the premiums of residents’ basic medical insurance already contributed shall not be refunded once the insured obtain employment or participate in employees’ basic medical insurance as flexible-employment personnel during the period when the insured of residents’ basic medical insurance enjoy the treatment.
Article 19 The transfer and continuation of the basic medical insurance relationship of the insured shall be carried out in accordance with relevant provisions of the State, Guangdong Province and this municipality.
Article 20 Those who participate in the basic medical insurance in other regions in accordance with the state provisions shall not participate in the employees’ basic medical insurance or the residents’ basic medical insurance in this municipality at the same time, and shall not enjoy the treatment of the employees’ basic medical insurance or the residents’ basic medical insurance repeatedly.
Chapter Ⅲ Fund Administration
Article 21 The basic medical insurance fund includes the basic medical insurance fund for employees and the basic medical insurance fund for residents, in which the basic medical insurance premiums for employees contributed by the employers participating in the insurance and the insured shall be included in the basic medical insurance fund for employees; the basic medical insurance premiums for residents shall be included in the basic medical insurance fund for residents.
The basic medical insurance fund for employees consists of the pooling fund of employees’ basic medical insurance and individual accounts; the basic medical insurance fund for residents sets up the pooling fund of residents’ basic medical insurance without setting up individual accounts.
The basic medical insurance pooling fund includes the pooling fund of employees’ basic medical insurance and the pooling funds of residents’ basic medical insurance.
Article 22 The medical expenses incurred by the insured that comply with the catalogue of medicines, diagnosis and treatment items, and medical consumable materials of basic medical insurance (hereinafter referred to as “basic medical expenses”) shall be paid from the fund of basic medical insurance in accordance with the provisions of these Measures.
Article 23 The basic medical insurance fund shall be incorporated into a specific financial account, managed in accordance with the principle of "separation between revenues and expenditures", with separate accounting. The fund shall be used for its specified purposes only, and shall not be appropriated or interchanged.
Article 24 The management of revenues and expenditures of the basic medical insurance fund shall follow the principle of determining expenditures according to revenues, maintaining a balance between revenues and expenditures, and maintaining a slight surplus.
Article 25 The sources of the basic medical insurance fund shall be:
(1) Incomes from basic medical insurance premiums;
(2) Incomes from financial subsidies;
(3) Incomes from interests;
(4) Incomes from financial transfer payment;
(5) Incomes from subsidies given by higher authorities; and
(6) Other incomes.
Article 26 The interests on the balance in the individual account of the insured shall be calculated in accordance with relevant provisions of the State and included in the individual account.
Article 27 The municipal healthcare security agency shall establish individual accounts for the insured of Tier I of the employees’ basic medical insurance, and the standards for the inclusion of individual accounts shall be subject to relevant provisions of the State and Guangdong Province. For retirees who have stopped contributing on premiums and are entitled to the benefits of Tier I of employees’ basic medical insurance, their individual accounts shall be transferred from the pooling funds of employees’ basic medical insurance.
Chapter Ⅳ Healthcare Security Benefits
Article 28 The insured begins to enjoy the benefits on medical insurance stipulated in these measures from the first day of the next month since he/she has gone through the formalities of participating insurance and contributing the basic medical insurance premiums in full.
The personnel stipulated in Item (1) of Clause 1 of Article 11 hereof who contributes the premium on residents’ basic medical insurance in a lump sum from September of the current year to August of the next year shall be entitled to the treatment of residents’ basic medical insurance from October of the current year to September of the next year.
If a newborn with household registration in this municipality goes through the formalities for participating in the residents’ basic medical insurance within six months after birth, he/she may contribute premiums from the month of birth. The one who contributes the premiums from the month of birth is entitled to enjoy the treatment of residents’ basic medical insurance prescribed in these Measures from the date of birth.
The insured suspending contribution on the basic medical insurance premiums shall cease to enjoy the medical insurance treatment paid by the overall basic medical insurance fund from the first day of the month following the one in which he/she suspends contribution, but the balance of the individual account may continue to be used.
Article 29 The catalogs and payment standards of drugs, diagnosis and treatment items, and medical consumables for the basic medical insurance shall be implemented in accordance with relevant provisions of the State, Guangdong Province and this municipality, and the critical illness insurance shall be implemented with reference to the expense scope stipulated by the basic medical insurance.
If the insured uses the drugs and diagnosis and treatment items under Class B of basic medical insurance, which are required by the State and Guangdong Province to be paid by himself/herself in advance, 1% of the expenses shall be paid by the individual in advance.
The expenses of the drugs negotiated by the State incurred in the outpatient service of the insured in the designated medical institution shall be paid by the overall fund of basic medical insurance as provided, and shall not be included in the calculation of the annual payment quota stipulated in Article 31, Clause 4 of Article 34.
Article 30 Except for the provisions of Article 32 and Article 33 of these Measures, the basic medical expenses of general outpatient incurred by the insured of employees’ basic medical insurance and the insured of residents’ basic medical insurance in the selected designated medical institutions under the overall planning shall be paid by the overall basic medical insurance fund at the proportion of 75% for medical institutions below the first tier, 65% for hospitals at the second tier and 55% for hospitals at the third tier. The payment proportion for retirees and the insured over 60 years old of the residents’ basic medical insurance shall be raised by 5% correspondingly.
Except for the need for emergency treatment, the basic medical expenses of general outpatient incurred by the insured in the non-selected designated medical institution under the overall planning without transfer shall not be paid by the overall basic medical insurance fund but may be paid from the individual accounts of the insured.
Article 31 Within a medical insurance year, the payment quota of the overall basic medical insurance fund for the basic medical expenses of general outpatient incurred by the insured in the selected designated medical institutions under the overall planning in this municipality shall be implemented in accordance with the following provisions:
(1) The maximum payment quota of the insured of Tier I of employees’ basic medical insurance shall not exceed 6% (7% for retirees) of the annual average salary of in-service employees of this municipality for the year before the preceding year, and the maximum payment quota for hospitals at the second tier or specialized hospital shall not exceed 3% (3.5% for retirees) of the annual average salary of in-service employees of this municipality for the year before the preceding year.
(2) The maximum payment quota of the insured of Tier I of employees’ basic medical insurance and the insured of residents’ basic medical insurance shall not exceed 1.5% of the annual average salary of in-service employees of this municipality for the year before the preceding year.
Article 32 If the basic medical expenses of the insured for outpatient service of the designated medical institutions in this municipality are diagnosis fees, the overall basic medical insurance fund shall pay the proportion of 80% for medical institutions below the first tier, 70% for hospitals at the second tier and 60% for hospitals at the third tier. The treatment of outpatient diagnosis fee shall not be enjoyed repeatedly with the treatment of other basic outpatient medical expenses paid by the overall basic medical insurance fund.
Article 33 The examination expenses using large medical equipment and basic medical expenses incurred by the insured of Tier I of employees’ basic medical insurance at designated medical institutions in this municipality shall be covered at the proportion of 80% by the pooling fund of employees’ basic medical insurance, and the treatment shall not be enjoyed repeatedly with the treatment of other basic outpatient medical expenses paid by the pooling fund of employees’ basic medical insurance. The scope of outpatient examination using large medical equipment and treatment items shall be separately formulated by the municipal healthcare security administrative department.
Article 34 If the insured has been diagnosed with a special outpatient disease (hereinafter referred to as “special disease”), the basic medical expenses of the special disease incurred in the selected medical institution during the period when he/she enjoys the insurance shall be paid by the overall basic medical insurance fund as provided. Special diseases are divided into Class A and Class B.
The basic medical expenses for Class A special diseases incurred by the insured shall be paid by the overall basic medical insurance fund in accordance with the following provisions:
(1) The payment is at the proportion of 60% for the insured participating in the insurance consecutively less than 12 months;
(2) The payment is at the proportion of 75% for the insured participating in the insurance consecutively more than 12 months but less than 36 months;
(3) The payment is at the proportion of 90% for the insured participating in the insurance consecutively more than 36 months.
The basic medical expenses for Class B special diseases incurred by the insured shall be paid by the overall basic medical insurance fund in accordance with the following provisions:
(1) The payment proportion of outpatient expenses for hypertension and diabetes drugs shall be pursuant to the provisions of Article 30, while the payment proportion of the expense is 90% for hypertension and diabetes drugs prescribed by the contracted family doctor if the insured receives chronic disease health management service in the designated community health institution in this municipality;
(2) For the basic medical expenses of other Class B special diseases, the payment proportion is 80% for the insured of Tier I of the employees’ basic medical insurance; the payment proportion is no less than 60% for the insured of Tier II of the employees’ basic medical insurance and the insured of the residents’ basic medical insurance.
The scope of special diseases shall be regulated in accordance with provisions of Guangdong Province. The classification of special diseases, period for entitlement to benefits, and annual payment quota shall be separately formulated by the municipal healthcare security administrative department.
Article 35 The individual account of the insured may be used to pay the expenses of himself/herself and his/her spouse, parents, children in compliance with the provisions of the State, Guangdong Province and this municipality.
Article 36 The part of the basic medical expenses incurred by the insured being hospitalized in the designated medical institution in this municipality, which does not exceed the starting payment line, shall be paid by the insured; the part exceeding the starting payment line shall be paid by the overall basic medical insurance fund in accordance with these Measures and the relevant supporting provisions.
The starting payment line for hospitalization is set according to the grades of the hospitals, in which RMB 200 for hospitals at the first tier or below, RMB 400 for hospitals at the second tier and RMB 600 for hospitals at the third tier.
If the insured is hospitalized two or more times within one medical insurance year, the starting payment line for hospitalization is: RMB 100 for hospitals at the first tier or below, RMB 200 for hospitals at the second tier and RMB 300 for hospitals at the third tier.
The starting payment line for hospitalization of the insured in other regions shall be the same as the standard of this municipality.
Article 37 The part of the basic medical expenses incurred by the insured being hospitalized in the designated medical institution in this municipality, which exceeds the starting line, shall be paid from the overall basic medical insurance fund in accordance with the following provisions:
(1) For the insured of Tier I of the employees’ basic medical insurance, the payment proportion is 94% for the hospitals at the first tier or below, 92% for the hospitals at the second tier, 90% for the hospitals at the third tier; for retirees, the payment proportion is 95%.
(2) For the insured of Tier II of the employees’ basic medical insurance, the payment proportion is 92% for the hospitals at the first tier or below, 91% for the hospitals at the second tier, 90% for the hospitals at the third tier; for retirees, the payment proportion is 95%.
(3) For the insured of the residents’ basic medical insurance, the payment proportion is 92% for the hospitals at the first tier or below, 91% for the hospitals at the second tier, 90% for the hospitals at the third tier; for the personnel aged 60 years old or above, the payment proportion is 95%.
Article 38 Within one medical insurance year, the accumulated payment quota of the overall basic medical insurance fund on the basic medical expenses of the insured incurred in Clause 3 of Article 29, Article 32, Article 33, Article 34, and Article 37 of these Measures shall comply with the following standards according to the consecutive time of the insured participating in basic medical insurance:
(1) If the consecutive time of participating in the insurance is less than 6 months, the payment quota shall be one time of the average annual salary of in-service employees of this municipality for the year before the preceding year;
(2) If the consecutive time of participating in the insurance is no less than 6 months but less than 12 months, the payment quota shall be two times of the annual average salary of in-service employees of this municipality for the year before the preceding year;
(3) If the consecutive time of participating in the insurance is no less than 12 months but less than 24 months, the payment quota shall be three times of the annual average salary of in-service employees of this municipality for the year before the preceding year;
(4) If the consecutive time of participating in the insurance is no less than 24 months but less than 36 months, the payment quota shall be four times of the annual average salary of in-service employees of this municipality for the year before the preceding year;
(5) If the consecutive time of participating in the insurance is no less than 36 months but less than 72 months, the payment quota shall be five times of the annual average salary of in-service employees of this municipality for the year before the preceding year;
(6) If the consecutive time of participating in the insurance is no less than 72 months, the payment quota shall be six times of the annual average salary of in-service employees of this municipality for the year before the preceding year.
Article 39 The term “consecutive time of participating in the insurance” as mentioned in these Measures refers to the consecutive time during which the insured actually contributes the basic medical insurance premium in this municipality. If the accumulative interruption of the insured within one medical insurance year does not exceed 3 months, the consecutive time of participation in the insurance before and after the interruption shall be calculated together after contributing the premium again; if the interruption exceeds 3 months, the consecutive time of participation in the insurance shall be recalculated.
If the insured pays the basic medical insurance premium in one lump sum, consecutive time of participating in the insurance shall be calculated month by month from the 1st of the next month of the contribution month.
If the insured switches between the employees’ basic medical insurance and the residents’ basic medical insurance, and the interruption of participation in insurance does not exceed 3 months, his/her consecutive time of participation in insurance shall be calculated together.
Article 40 The insured may be entitled to the direct settlement service for non-local medical treatment and benefit under the following provisions upon completion of the non-local medical treatment registration formalities as required:
(1) If the insured has gone through long-term non-local medical treatment registration or formalities for referral procedures outside this municipality in accordance with the provisions of the State, Guangdong Province and this municipality, the payment proportion of basic medical expenses directly settled in the designated medical institutions outside this municipality shall be the payment proportion of medical expenses incurred in this municipality;
(2) If the insured receives emergency treatment in other places, the payment proportion of basic medical expenses directly settled in the designated medical institutions outside this municipality shall be 90% of the payment proportion of medical expenses incurred in this municipality;
(3) For other insured who temporarily go out for medical treatment, the payment proportion of basic medical expenses directly settled in the designated medical institutions outside this municipality shall be 80% of the payment proportion of medical expenses incurred in this municipality. The payment proportion of basic medical expenses directly settled in the designated medical institutions outside this municipality but in Guangdong Province shall be 90% of the payment proportion of medical expenses incurred in this municipality.
If the basic medical expenses incurred by the insured for medical services in other places cannot be directly settled for certain reasons, the medical reimbursement of the relevant medical expenses incurred by the insured that conform to the provisions of this municipality may be applied to the municipal healthcare security agency. The specific measures shall be separately formulated by the municipal healthcare security administrative department.
Article 41 Within the same medical insurance year, the payment quota of the overall basic medical insurance fund for the insured incurred in the designated medical institutions in and outside this municipality shall not exceed the corresponding annual maximum payment quota of this municipality.
Article 42 The hospitalization medical expenses of the insured shall be implemented in accordance with the treatment standard of the form of medical insurance at the time of admission to the hospital.
Article 43 The following medical expenses incurred by the insured shall be covered by the scope of critical illness insurance:
(1) The part of expenses of hospitalization and special disease paid by the overall basic medical insurance fund according to these Measures exceeding the annual payment quota of the overall basic medical insurance fund and the payment quota of special disease;
(2) The basic medical expense of hospitalization and special disease subject to the insured’s self-paid basic medical expense, except the reduction of the payment proportion of basic medical insurance as referred in Item (1) and (3) of Clause 1 of Article 40;
(3) The insured’s self-paid basic medical expense of drugs negotiated by the State incurred in the designated medical institution outpatient clinics;
(4) Expenses below the starting payment line for hospitalization;
(5) Other expenses stipulated by the State, Guangdong Province and this municipality.
The expenditure of critical illness insurance benefits shall be listed in the expenditure of the overall basic medical insurance fund.
Article 44 The medical expenses of the insured which conform to the provisions of Article 43 of these Measures, within one medical insurance year, shall be paid at the proportion of 70% of the accumulated part between RMB 10,000 and RMB 30,000 by the overall basic medical insurance fund; 80% of the accumulated part over RMB 30,000 shall be paid by the overall basic medical insurance fund.
Article 45 Within one medical insurance year, the payment quota of the critical illness insurance shall be implemented according to the consecutive time of participating in basic medical insurance and the following standards:
(1) If the consecutive time of participating in the insurance is less than 6 months, the amount shall be RMB 50,000;
(2 If the consecutive time of participating in the insurance is over 6 months but less than 12 months, the amount shall be RMB 100,000;
(3) If the consecutive time of participating in the insurance is over 12 months but less than 24 months, the amount shall be RMB 150,000;
(4) If the consecutive time of participating in the insurance is over 24 months but less than 36 months, the amount shall be RMB 200,000;
(5) If the consecutive time of participating in the insurance is over 36 months but less than 72 months, the amount shall be RMB 500,000;
(6) If the consecutive time of participating in the insurance is over 72 months, the amount shall be RMB 1,000,000.
Article 46 For the insured who meet the scope of medical assistance in this municipality, the basic medical expenses incurred in accordance with the provisions of Article 43 of these Measures, within one medical insurance year, shall be paid at the proportion of 80% of the accumulated part between RMB 2,000 and RMB 30,000 by the overall basic medical insurance fund; 90% of the accumulated part over RMB 30,000 shall be paid by the overall basic medical insurance fund. No maximum annual payment quota shall be set.
Article 47 The following medical expenses of the insured shall not be included in the payment scope of the basic medical insurance fund:
(1) Expenses which are supposed to be paid by the work injury insurance fund;
(2) Expenses which are supposed to be borne by the third party;
(3) Expenses which are supposed to be borne by public health;
(4) Expenses incurred for overseas medical treatment; and
(5) Any other non-payable expenses stipulated by the State and Guangdong Province.
If in the event that the medical expenses shall be borne by the third party pursuant to the law, but the third party fails to pay or the third party cannot be determined, the insured may apply to the municipal healthcare security agency for advance payment in accordance with the relevant provisions of the State and Guangdong Province. After the basic medical insurance fund makes advance payment, the municipal healthcare security agency has the right to recover the payment from the third party.
Chapter Ⅴ Medical Treatment and Service Administration
Article 48 The insured receiving general outpatient treatment, or outpatient treatment for special disease may select the designated medical institution according to the provisions and enjoy the medical insurance benefits prescribed in these Measures. The specific measures on selection for medical treatment shall be separately formulated by the municipal healthcare security administrative department.
Article 49 The municipal healthcare security administrative department shall formulate the management system for designated medical institutions and designated retail pharmacies based on the needs of public health, regional health planning, medical institution establishment planning, and the medicine needs of the insured, and shall supervise and administer designated medical institutions and the designated retail pharmacies.
The municipal healthcare security agency shall be responsible for determining designated medical institutions and retail pharmacies, signing medical insurance agreements with them, providing agency services, and carrying out management and assessment of medical insurance agreements, etc.
Article 50 Designated medical institutions and designated retail pharmacies shall strictly implement the relevant government policies and provisions on the charging standards for medical services and the prices of medicines and medical consumables, and shall publish the relevant information.
Designated medical institutions shall provide the insured with the detailed list of outpatient or daily hospitalization charges and other documents.
Designated medical institutions and designated retail pharmacies shall strengthen internal management, provide necessary and reasonable services for the insured in accordance with the provisions of the state and Guangdong Province on the management of designated healthcare security institutions and the agreement on medical insurance, and accept and cooperate in supervision.
Article 51 The municipal healthcare security administrative department shall, according to relevant requirements of the State on deepening the healthcare security reform, push forward the reform in the payment mode of medical insurance, adopt the compound payment system mainly by capitation for outpatient service and by disease type for hospitalization and the settlement method of advance payment at the beginning of the year, monthly payment and year-end settlement on the principles of total amount budget, retention of surplus and sharing of rational over-expenditures. The specific management measures on expense settlement shall be separately formulated by the municipal healthcare security administrative department.
Article 52 Public designated medical institutions in this municipality shall, based on actual needs and under the principles of quality priority, reasonable price, timely supply and efficient service, select at their own discretion the qualified transaction platform to purchase drugs and medical consumables.
Non-public designated medical institutions and designated retail pharmacies shall be encouraged to purchase drugs and medical consumables through qualified transaction platforms.
Article 53 Public designated medical institutions in this municipality shall perform their responsibilities for procurement of drugs and medical consumables and implement the management provisions of the State, Guangdong Province and this municipality on procurement of drugs and medical consumables as required.
Article 54 Designated medical institutions and designated retail pharmacies shall, in accordance with the relevant provisions and requirements, cooperate in the administration of medicine price monitoring, and promptly, completely and accurately provide the relevant data and information on medicine price monitoring.
Article 55 In the event that the electronic medical insurance certificate, social security card, resident ID card, or other identity certifications for medical insurance service of the insured are illegally used due to improper custody, the insured shall bear the loss of the individual account caused thereby.
Chapter Ⅵ Supervision and Administration
Article 56 The municipal healthcare security agency shall establish and strengthen the financial system of the basic medical insurance fund, and regularly publicize to the public the surplus of the basic medical insurance fund.
Article 57 Municipal and district health departments shall supervise and administer designated medical institutions, regulate the qualifications and diagnostic and treatment practices of designated medical institutions to provide medical services, including the implementation of the healthcare security provisions by public medical institutions in the assessment of the comprehensive target administration of public medical institutions, and include the same in the tenure target responsibility system of the person in charge.
The supervision conducted by the municipal and district health departments over medical institutions and medical and health personnel shall be taken as an important basis for medical institutions to manage their medical insurance agreements.
Article 58 The municipal department of market supervision and regulation shall supervise and inspect designated medical institutions and designated retail pharmacies to implement the pricing policies of the State, Guangdong Province and this municipality on prices of medical services, drugs and medical consumables, strengthen the management of licensed pharmacists of designated retail pharmacies and the circulation supervision and administration of drugs and medical consumables, and standardize business activities of drugs and medical consumables.
The municipal departments of finance and audit shall exercise supervision over the income and expenditure, carry-over and management situation of the medical insurance fund according to law.
Article 59 The municipal healthcare security agency shall promptly, completely and accurately record the insured’s rights and interests such as participation in medical insurance, contribution on premiums, enjoyment of benefits, etc., and provide the services of inquiry of personal rights and interests according to law.
Article 60 The municipal healthcare security administrative department shall carry out supervision and inspection over designated medical institutions and designated retail pharmacies and have the right to use information technology means to carry out real-time monitoring on the use of the medical insurance fund, and consult, record and copy relevant information system data, and have the right to inquire the entities and individuals in relation to the investigated matters and require them to make explanations on the investigated matters and provide relevant evidentiary materials.
Article 61 The municipal healthcare security agency shall inspect and verify the designated institutions and designated retail pharmacies in accordance with the medical insurance agreement and the handling procedures.
Designated institutions and designated retail pharmacies shall provide relevant medical insurance materials as stipulated. In case of failure to provide the corresponding materials, the municipal healthcare security agency may refuse to pay the corresponding expenses.
Article 62 If the municipal healthcare security administrative department finds any abnormality in the medical insurance bookkeeping of the insured, it may inform the insured by telephone or in writing to explain the situation; if the insured cannot be contacted within two working days by the aforementioned means, it may suspend the networking settlement of the medical expenses of the insured. The medical expenses incurred by the insured during the suspension of networking and settlement shall be fully paid by the individual in advance.
The municipal healthcare security administrative department shall resume the bookkeeping of medical expenses, and the municipal healthcare security agency shall, in accordance with the Measures, reimburse the medical expenses incurred during the suspension period, if no illegal or rule-breaking situation is found after contact with the insured; if violations are found through investigation, the municipal healthcare security administrative department shall handle in accordance with relevant provisions.
Article 63 Any organization or individual shall have the right to report or complain about any illegal or irregular act of infringing upon the medical insurance fund.
The municipal healthcare security administrative department shall unblock the channels for reports and complaints, promptly handle relevant reports and complaints according to law, and keep the information of the reporter confidential. If the report is verified to be true, the reporter shall be rewarded in accordance with relevant provisions of this municipality. The reward funds shall be included in the budget of the municipal healthcare security administrative department.
Chapter Ⅶ Legal Liabilities
Article 64 If the employer fails to register for participating in the basic medical insurance, or fails to contribute the premiums in full and on time in accordance with the provisions of these Measures, it shall be dealt with in accordance with the Social Insurance Law of the People’s Republic of China and other relevant laws and regulations.
Article 65 If the employer fails to go through the medical insurance registration for employees in accordance with relevant provisions or contribute the medical insurance premiums in full and on time, which causes that the employees cannot enjoy or enjoy in full the benefits of medical insurance, the employer shall pay relevant expenses in accordance with the benefit standard of the medical insurance as stipulated in these Measures.
Article 66 Individual payers who do not contribute basic medical insurance premiums in full and on time shall not be allowed to make a supplementary contribution.
Article 67 Any designated medical institution or designated retail pharmacy that violates the medical insurance agreements entered into with the municipal healthcare security agency shall be dealt with by the municipal healthcare security agency in accordance with provisions of the medical insurance agreements; any violation of the provisions of the State, Guangdong Province and this municipality shall be dealt with by the municipal healthcare security administrative department in accordance with relevant provisions.
Article 68 The municipal healthcare security administrative department shall, in accordance with the laws and regulations, establish and strengthen the healthcare security credit evaluation system, and conduct graded and classified administration based on credit evaluation ratings. The bad credit information of any organization or individual in violation of the healthcare security laws and regulations shall be included in the credit evaluation system of this municipality.
Article 69 If the municipal healthcare security administrative department, municipal healthcare security agency, basic medical insurance premiums collection agency and their staff members abuse their authority, neglect their duties, or engage in malpractice for personal gains in the course of healthcare security work, they shall be punished according to law.
Article 70 Any employer or individual that is dissatisfied with the administrative act of the healthcare security administrative department, the municipal healthcare security agency, or the basic medical insurance premiums collecting agency may apply for administrative reconsideration or bring administrative litigation according to law.
If designated medical institutions or designated retail pharmacies deem that medical security agencies have violated the medical insurance agreements, they may resolve the issue through negotiation by themselves or request healthcare security administrative departments to coordinate for settlement, or may apply for administrative reconsideration or bring administrative litigation according to law.
Chapter Ⅷ Supplementary Provisions
Article 71 Enterprises may withdraw enterprise supplementary medical insurance premiums at an amount of no more than 4% of the total employee salary from employee welfare funds to pay the enterprise supplementary medical insurance treatment.
Article 72 The healthcare security provisions for medical aid targets shall be formulated separately by the municipal healthcare security administrative department jointly with other relevant departments.
Article 73 Urbanized personnel of this municipality shall participate in the employees’ basic medical insurance through shareholding cooperative companies as employers and contribute premiums.
Article 74 If the retiree participating in the endowment insurance treatment of an entity located in Shenzhen overall planned by the original endowment insurance industry and enjoying endowment insurance paid monthly by the social insurance institution of Guangdong Province and Beijing Municipality has affirmed this municipality as the place where he/she enjoys basic medical insurance benefits for employees after retirement and has insufficient contribution years and needs to continue the contribution, the original employer shall make contribution for the required years at one time in accordance with these Measures.
Article 75 For the personnel who has contributed the medical insurance premiums in a lump sum and transferred the premiums to his/her individual account before the implementation of these Measures, the transfer of his/her individual account shall be implemented in accordance with the original provisions and the standard may not be lower than the transfer standard for the individual account of the retiree. Upon expiration of the contribution years, the employee shall continue to enjoy Tier I benefits of the employees’ basic medical insurance. The individual account shall be included in accordance with the relevant provisions of Guangdong Province and the payment shall be made from the pooling fund of the employees’ basic medical insurance.
Article 76 The determination of the years of medical insurance for veterans shall be subject to the relevant provisions of the State, Guangdong Province and this municipality, and the years of active service shall be deemed as the actual contribution period for Tier I of employees’ basic medical insurance in this municipality. If the veteran participates in the insurance and contributes the premiums in the month when being transferred to and accepted by this municipality, he/she is entitled to the medical insurance benefits as provided by these Measures from the month when the premiums are paid.
Article 77 During the period of receiving unemployment insurance benefits, if the unemployed personnel stops participating in insurance due to handling the procedures for receiving unemployment insurance benefits for no more than 30 days, he/she shall be regarded as participating in the original form of medical insurance and shall enjoy the corresponding treatment.
Article 78 If the insured of employees’ basic medical insurance retires after December 1, 2022, has insufficient contribution years and continues to contribute medical insurance premiums of Tier I of the employees’ basic medical insurance, the contribution standard shall be implemented in accordance with the provisions of Clause 3 of Article 10 hereof.
Article 79 If the employer or any of its employees fails to contribute medical insurance premiums in accordance with relevant provisions and exceeds the time limit for investigation and punishment of illegal acts stipulated in the Regulations on Labor Security Supervision, the arrears for medical insurance premiums may be applied for supplementary contribution. Supplementary medical insurance premiums to be paid shall be credited to the overall employees’ basic medical insurance and individual accounts pursuant to the provisions. If the employee does not participate in medical insurance pursuant to the provisions, he/she shall be dealt with as Tier I of employees’ basic medical insurance.
Article 80 The term “employers” mentioned in these Measures shall refer to organs, public institutions, enterprises, social groups, foundations, social service agencies and individual economic organizations in the administrative area of this municipality.
The term “employer participating in the insurance” mentioned in these Measures shall refer to the employers that have participated in the basic medical insurance of this municipality.
The term “the insured” mentioned in these Measures shall refer to the personnel that has participated in the basic medical insurance of this municipality.
The term “flexible-employment personnel” mentioned in these Measures shall refer to the following personnel who are within the statutory working age and are employed in the municipality: individual businesses with no employees, part-time employees who have not participated in the employees’ basic medical insurance in their employers, employees of new forms of employment who have achieved employment by relying on platforms of new forms of business such as e-commerce, online car-hailing, online food delivery and express logistics and have not established employment relations with platform enterprises of new forms of business, and other flexible-employment personnel stipulated by the State and Guangdong Province.
The term “retirees” mentioned in these Measures shall refer to personnel who stop contributing premiums upon reaching the statutory retirement age and enjoy the basic medical insurance benefits for employees in this municipality, as well as the personnel who have enjoyed the endowment insurance benefits for employees or received pensions before December 1, 2022, but continue to contribute the basic medical insurance premiums for employees in this municipality.
The term “designated medical institutions in this municipality” mentioned in these Measures shall refer to the medical institutions which voluntarily conclude medical insurance agreements with the municipal healthcare security agencies to provide medical services for the insured.
The term “designated retail pharmacies in this municipality” mentioned in these Measures shall refer to the retail pharmacies which voluntarily conclude medical insurance agreements with the municipal healthcare security agencies to provide drug services for the insured.
The term “basic medical insurance premiums collection agency” mentioned in these Measures shall refer to the departments and agencies in charge of the verification and collection of the contribution on basic medical insurance premiums, in accordance with the collection and contribution modes of basic medical insurance premiums provided in the relevant documents of the State, Guangdong Province and this municipality.
Article 81 The insured of employees’ basic medical insurance shall participate in maternity insurance and enjoy benefits in accordance with the Rules of Guangdong Province on Maternity Insurance of Employees. Maternity insurance premiums shall be contributed in accordance with the following provisions:
(1) The maternity insurance premiums of employees in service shall be contributed monthly by the employer, the contribution base shall be the contribution base on basic medical insurance premiums of their employees, and the payment proportion shall be 0.5%;
(2) For unemployed persons during the period of receiving unemployment insurance benefits, the payment base shall be the average monthly salary of the full-caliber urban employees of this municipality for the year before the preceding year. The payment proportion shall be 0.5%, and the payment shall be disbursed from the unemployment insurance fund.
The maternity insurance benefits of employees shall be paid by the pooling fund of employees’ basic medical insurance.
Article 82 The maternity medical expenses incurred by the insured of residents’ basic medical insurance shall be entitled to benefits with reference to the relevant provisions and standards of the Rules of Guangdong Province on Maternity Insurance of Employees and the expenses shall be paid by the pooling funds of residents’ basic medical insurance.
Article 83 Personnel from Hong Kong SAR, Macao SAR and Taiwan Province shall participate in basic medical insurance pursuant to the relevant provisions of the State, Guangdong Province and this municipality.
Article 84 The term “medical insurance year” as mentioned in these Measures shall refer to the period from January 1st to December 31st each year.
Article 85 These Measures shall come into force on October 1st, 2023, and the Measures of the Shenzhen Municipality on Social Medical Insurance (No. 256 of the Order of the Shenzhen Municipal People’s Government) shall be repealed simultaneously.
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