First, about the scope of overall burden reduction.
The self-funded medical expenses incurred by the insured during the period of enjoying the basic medical insurance for urban workers in Shanghai, including the self-employed and freelancers who pay the medical insurance premium at the rate of 14%, are included in the comprehensive burden reduction scope.
Two, about the determination and audit of the annual income of employees.
(A) the determination of the annual income of employees
In principle, the annual income of employees who participate in comprehensive burden reduction is calculated according to the annual income of the previous year (natural year), that is, the annual income of the previous year based on comprehensive burden reduction in this medical insurance year (April of that year 1 to March of the following year 1) is June 65438+1October1to February 365438.
1. If there is no monthly income in the previous year, it can be converted into adult income according to the average monthly income standard of the previous year.
2. In the middle of this year (including new insurance or re-insurance), if there is no income in the previous year, it will be converted into adult income according to the average monthly income of that year.
3, this year, the new retirees into the city insurance, no previous annual income, can refer to the average monthly pension standard, converted into adult income.
4. If the annual income of the current year is lower than that of the previous year, I can choose to convert adult income according to the average monthly income standard of the current year according to my wishes.
After the above-mentioned annual income is determined, it will not be changed in principle within a medical insurance year.
(two) the proof and audit of the annual income of employees.
The county medical insurance affairs center shall review the application form for comprehensive burden reduction of basic medical insurance for urban workers in Shanghai (hereinafter referred to as the application form) submitted by the insured. Among them, the personal income items shall be certified and sealed by the relevant units (departments).
1. When employees apply for comprehensive burden reduction, if they have a work unit at present, their work units shall affix official seals (including official seals, labor and personnel seals, trade union seals, etc.) in the relevant columns of the application form. , the same below) to prove; At present, people who have no work unit (including those who have not been re-employed, self-employed and freelancers who have participated in urban insurance, and those who have work units but are currently unemployed) can be stamped in the relevant columns of the application form by the functional departments designated by the neighborhood offices (township governments) of their domicile or residence. If the declared personal income is obviously unreasonable (obviously non-annual income), it should be verified with the above-mentioned relevant units or departments. If there is any mistake, it shall be corrected by the relevant unit or department according to the facts.
2. When retirees apply for comprehensive burden reduction, the county medical insurance affairs center can verify their pension income through the "12333" social security network. Among them, if a personal password is set, you can ask me to enter the password before making an inquiry.
For retirees who have not participated in the old-age insurance in this Municipality (such as the home of retired cadres), the management unit shall seal the certificate.
3. For those who changed from on-the-job to retired in the middle of last year, their annual income can be converted according to the pension standard of the first month of last year. If you can provide proof of income before retirement (the "Application Form" is certified and sealed by the original unit), you can calculate the annual income separately according to the accumulated on-the-job and retirement.
(3) In the medical insurance year of 2004, the minimum wage in the previous year was 6840 yuan, the average annual wage of employees was 0.5 times of 65438+33240 yuan, and the average annual wage of employees was 3 times of 66480 yuan.
Three, on the convergence with other burden reduction policies
(1) In the year of medical insurance in 2004 (as of March 3, 20051day), both comprehensive burden reduction and current high burden reduction can be applied. Specific measures are as follows:
1. If the self-funded medical expenses of the insured meet the high burden reduction standard, it shall be implemented according to the relevant provisions of the high burden reduction. After the completion of the high burden reduction, the remaining self-funded medical expenses (after deducting the reduced part, the same below) shall be handled in the following two cases:
(1) If the remaining self-funded medical expenses meet the comprehensive burden reduction standard, comprehensive burden reduction shall be carried out after the completion of the current high burden reduction, and the current burden reduction operation shall be completed after the completion of the comprehensive burden reduction.
(2) If the remaining self-funded medical expenses do not meet the comprehensive burden reduction standard, after the current high burden reduction is completed, the remaining self-funded medical expenses can be included in the calculation range of the subsequent comprehensive burden reduction self-funded medical expenses;
2, the insured person's medical expenses meet the comprehensive burden reduction but have not yet reached the high burden reduction standard, respectively, according to the following two situations:
(1) Among the self-funded medical expenses, if the self-funded medical expenses of hospitalization (including emergency care) and family beds reach the comprehensive burden reduction standard, the self-funded medical expenses of hospitalization and family beds can be comprehensively reduced first;
(2) Among the self-funded medical expenses, if the accumulated self-funded medical expenses of hospitalization (including acute care) and family beds do not meet the comprehensive burden reduction standard, the application for burden reduction will not be accepted temporarily. By the end of this medical insurance year, if the self-funded medical expenses have not reached the high burden reduction standard but reached the comprehensive burden reduction standard, they can be reduced according to the comprehensive burden reduction policy. Among them, if the medical insurance relationship is terminated in the middle of the medical insurance year (such as death), the comprehensive burden reduction can be handled before the personal medical account is liquidated.
(two) before the overall burden reduction of the insured, the following medical insurance burden reduction work should be completed first:
1, dialysis personnel to reduce the burden (medical institutions);
2, mental illness hospitalization deductible burden reduction (medical institutions);
3, low-income people with difficulties in hospitalization deductible burden reduction (medical insurance center operation);
4. In 2002 and 2003, the standard deviation of outpatient and emergency departments was partially reduced (operated by medical insurance center).
(three) the insured to participate in the Federation of trade unions mutual insurance plan, before applying for high burden reduction and comprehensive burden reduction, should go through the payment procedures at the trade union department. The county medical insurance center should explain the situation to the insured before handling the high and comprehensive burden reduction.
At present, due to the non-real-time transmission of relevant information between the medical insurance department and the trade union department, if there are major outpatient diseases and hospitalization expenses, the medical insurance department can accept the relevant application for reducing the burden 10 days after the trade union department completes the payment procedures (the shortest time limit is 20 days after the medical expenses occur).
(four) the insured enjoy Medicaid for civil servants, should apply for comprehensive burden reduction before handling the formalities of Medicaid for civil servants, and then apply for comprehensive burden reduction.
Four, other provisions on the comprehensive burden reduction action.
(1) In a medical insurance year, when applying for comprehensive burden reduction for the first time, the insured should fill in the application form and go through the certification procedures, and then it is no longer necessary to submit the application form when applying for comprehensive burden reduction.
(2) When the insured applies for reducing the burden for the first time, he only needs to fill in the application form and go through the relevant certification procedures, and does not need to fill in the original application form for reducing the burden by a large amount.
(3) At present, those who participate in individual insurance and urban insurance have participated in the basic medical insurance for urban workers, and the medical expenses incurred during the period meet the requirements of reducing the burden, the district and county medical insurance affairs center shall fill out the Application Form for Service Window Business Support, and the municipal medical insurance affairs center will not change its applicable Medical Insurance Measures for the time being, and then carry out the burden reduction operation.
(four) the comprehensive burden reduction base and the amount of burden reduction are calculated according to the principle of "taking the system as the benchmark and taking the income as the adjustment", and the high burden reduction is also operated according to this principle.
After the county medical insurance affairs center enters the corresponding data (such as income, medical allowance for civil servants, etc.), the operating system will automatically generate all the amounts that can be reduced from the last application for reducing the burden to this application for reducing the burden. If the insured has no objection to this amount, he can complete the restoration operation according to the relevant tips of the operating system; If the insured person has any objection, if it is verified by the county medical insurance affairs center that the amount of burden reduction is different due to classification conceit or other types, the amount can be adjusted according to the receipt of medical expenses provided by the insured person, and then the operating system regenerates the amount of burden reduction, and the burden reduction operation is completed according to the relevant tips of the operating system.
(five) accept the receipt of comprehensive burden reduction of medical expenses, kept by the county medical insurance affairs center, the specific retention, storage and archiving measures shall be formulated separately.
Five, about the designated medical care
In order to steadily implement the relevant policies of comprehensive burden reduction, in the initial stage of comprehensive burden reduction, designated medical care was tried out for those who applied for comprehensive burden reduction, including only outpatient and emergency medical expenses. Before handling the overall burden reduction, if there is a "sinking community" pilot community medical institution in the place of residence or work, the district and county medical insurance affairs center shall promptly inform it to go through the designated medical procedures for outpatient service. When applying for comprehensive burden reduction again, those who have not gone through the designated medical procedures shall be informed again, but the overall burden reduction will not be affected for the time being.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.