Li Keqiang Signs State Council Order to Publish Regulations on Supervision and Administration of the Use of Medical Security Funds

These Regulations are formulated in accordance with the Social Insurance Law of the People's Republic of China and other relevant legal provisions in order to strengthen the supervision and management of the use of medical security funds, ensure the safety of funds, promote the effective use of funds and safeguard the legitimate rights and interests of citizens' medical security.
2 these Regulations shall apply to the use and supervision and management of medical security funds such as the Basic Medical Insurance (including Maternity Insurance) Fund and the Medical Assistance Fund within the territory of the People's Republic of China.
3, the use of medical security funds adheres to the people's health as the center, the level of protection is in line with the level of economic and social development, and follows the principles of legality, safety, openness and people-to-people.
4 the use of medical security funds to exercise government supervision, social supervision, industry self-discipline and personal trustworthy combination.
article 5 The people's governments at or above the county level shall strengthen their leadership over the supervision and management of the use of medical security funds, establish and improve the mechanism for the use of medical security funds and the system of supervision and enforcement of the use of funds, strengthen the capacity-building of the use of medical security funds for supervision and management, and provide guarantees for the use of medical security funds for supervision and management.
6 The administrative department of medical security under the State Council shall be in charge of the supervision and management of the use of the national medical security fund.
other relevant departments of the State Council shall be responsible for the supervision and management of the use of the relevant medical security funds within their respective areas of responsibility.
administrative department of medical security of the local people's government at or above the county level shall be responsible for the supervision and management of the use of the medical security fund in the administrative area.
departments of the local people's governments at or above the county level shall be responsible for the supervision and management of the use of the relevant medical security funds within their respective areas of responsibility.
Article 7 The State encourages and supports the news media to carry out public welfare publicity on medical security laws, regulations and knowledge of medical security, and supervises the use of medical security funds by public opinion.
publicity reports on medical security should be true and fair.
the people's governments at or above the county level and their administrative departments, such as medical security, shall, through written consultations and symposiums, listen to the opinions of deputies to the National People's Congress, members of the CPPCC and representatives of insured persons on the use of medical security funds, open channels of social supervision, and encourage and support all sectors of society to participate in the supervision of the use of medical security funds.
Medical institutions, pharmaceutical business units (collectively called pharmaceutical institutions) and other units and medical and health industry associations shall strengthen self-discipline in the industry, standardize the conduct of pharmaceutical services, promote industry norms and self-restraint, and guide the rational use of medical security funds in accordance with the law.
the use of The second chapter of the fund Article 8 medical security fund shall conform to the scope of payment prescribed by the State.
scope of payment for medical security funds shall be formulated by the administrative department of medical security under the State Council in accordance with the law.
people's governments of provinces, autonomous regions and municipalities directly under the Central Government shall, in accordance with the authority and procedures prescribed by the State, supplement and formulate specific items and standards for the payment of medical security funds within their administrative areas and report them to the administrative department of medical security under the State Council for the record.
Article 9 The State shall establish and improve a unified national management system for the operation of medical security, provide standardized and standardized medical security management services, and achieve full coverage of provinces, cities, counties, townships (streets) and villages (communities).
Article 10 Medical security agencies shall establish and improve their business, financial, security and risk management systems, do a good job in the management of service agreements, cost monitoring, fund allocation, treatment review and payment, and regularly disclose to the public the income, expenditure and balance of medical security funds and accept social supervision.
Article 11 Medical security agencies shall establish a mechanism for collective bargaining and consultation with fixed-point pharmaceutical institutions, reasonably determine the budget amount and time limit for the allocation of medical security funds for designated medical institutions, and negotiate and sign service agreements with fixed-point medical institutions in accordance with the need to safeguard public health needs and manage services, regulate the conduct of medical services, and clarify the violation of service agreements and their responsibilities.
medical security agencies shall promptly publish to the community the list of designated medical institutions that have signed service agreements.
departments of medical security shall strengthen supervision over the conclusion and performance of service agreements.
Article 12 The medical security agency shall settle and allocate the medical security fund in a timely manner in accordance with the provisions of the service agreement.
designated pharmaceutical institutions shall provide medical services in accordance with the provisions, improve the quality of service, make rational use of medical security funds, and safeguard the health rights and interests of citizens.
Article 13 If a fixed-point pharmaceutical institution violates the service agreement, the medical security agency may urge it to perform the service agreement, suspend or not allocate the payment fees in accordance with the service agreement, recover the illegal expenses, suspend the medical services of the relevant responsible personnel or their departments involved in the use of the medical security fund until the service agreement is lifted;
if a medical security agency violates a service agreement, the designated medical institution shall have the right to request correction or to submit it to the administrative department of medical security for coordination, to supervise and rectify the situation, or to apply for administrative reconsideration or initiate administrative proceedings in accordance with the law.
14 fixed-point pharmaceutical institutions shall establish an internal management system for the use of medical security funds, and specialized agencies or personnel shall be responsible for the management of the use of medical security funds, and establish and improve an appraisal and evaluation system.
designated medical institutions shall organize and conduct training on the relevant systems and policies of the Medical Security Fund, regularly check the use of the medical security fund of their units, and promptly correct the irregular use of the Medical Security Fund.
Article 15 Fixed-point pharmaceutical institutions and their staff shall implement the regulations on the management of real-name medical treatment and purchase of medicines, verify the medical security certificates of the insured persons, provide reasonable and necessary medical services in accordance with the medical treatment norms, truthfully issue expense documents and related information to the insured persons, and shall not decompose the hospitalization or hospitalization, nor violate the hospitalization of the insured persons. The norms of diagnosis and treatment are excessive diagnosis and treatment, over-examination, decomposition of prescriptions, over-prescription of medicines, repeated prescriptions, no repeated charges, over-standard charges, decomposition of project charges, no cross-exchange of drugs, medical supplies, medical treatment items and service facilities, and no inducement or assistance to others under false names or false medical treatment or purchase of drugs.
The designated medical institution shall ensure that the expenses paid by the medical security fund meet the prescribed scope of payment, and that, except in exceptional circumstances such as emergency or rescue, the medical services provided outside the scope of payment of the medical security fund shall be approved by the insured persons or their next of kin or guardians.
article 16 Fixed-point medical institutions shall, in accordance with the provisions, keep financial accounts, accounting vouchers, prescriptions, medical records, treatment examination records, details of expenses, records of access to medicines and medical supplies, etc., transmit the relevant data on the use of medical security funds in a comprehensive and accurate manner through the medical security information system, report to the administrative department of medical security the information necessary for the supervision and management of the use of medical security funds, disclose to the public information on medical expenses, cost structure and so on, and accept social supervision.
Article 17 Insured persons shall seek medical treatment, purchase medicines and take the initiative to present them for examination with their medical security certificates.
shall have the right to request the fixed-point pharmaceutical institutions to truthfully issue expense documents and related information.
shall properly keep their medical security vouchers to prevent others from using them under the pretation.
if, for special reasons, he needs to entrust another person to purchase the medicine on his behalf, he shall provide the identification of the principal and the trustee.
shall enjoy medical security treatment in accordance with the provisions and shall not be repeated.
the right to request medical security consulting services from medical security agencies and to make suggestions for improvement in the use of medical security funds.
Article 18 In the course of the use of medical security funds, administrative departments such as medical security, medical security agencies, designated medical institutions and their staff shall not accept bribes or obtain other illegal income.
Article 19 Insured persons shall not take advantage of the opportunity to enjoy medical security treatment to resold medicines and accept the return of cash, in kind or other illegal benefits.
designated pharmaceutical institutions shall not facilitate the sale of medicines by insured persons to take advantage of their medical security treatment to accept cash returns, in kind or other illegal benefits.
article 20 Medical security agencies, designated medical institutions and other units and their staff and insured personnel shall not defraud medical security funds by falsifying, altering, concealing, altering, destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant information, or fictitious medical services items.
21, no organization or individual may appropriate or misappropriate the funds earmarked for medical security.
Chapter III Supervision and Management Article 22 Medical security, health care, Chinese medicine, market supervision and management, finance, auditing, public security and other departments shall work together in a division of labor, cooperate with each other, establish mechanisms for communication and coordination, transfer of cases, etc., and jointly do a good job in the supervision and management of the use of medical security funds.
administrative department for medical security shall strengthen supervision over the conduct of medical services and medical expenses included in the scope of payment of the medical security fund, regulate the operation of medical security, and investigate and punish the illegal use of medical security funds in accordance with the law.
Article 23 The administrative department of medical security under the State Council shall be responsible for formulating measures for the management of service agreements, regulating, simplifying and optimizing the procedures for fixed-point applications, professional evaluation and negotiation of pharmaceutical institutions, and producing and regularly revising model service agreements.
the administrative department of medical security under the State Council to formulate measures for the management of service agreements, it shall listen to the opinions of relevant departments, pharmaceutical institutions, trade associations, the public and experts.
article 24 The administrative department of medical security shall strengthen the exchange and sharing of information with relevant departments, innovate the way of supervision and management, promote the use of information technology, establish a unified, efficient, compatible, convenient and secure medical security information system, implement real-time dynamic and intelligent monitoring of big data, and strengthen the management of the whole process of sharing data to ensure the security of shared data.
25 The administrative department of medical security shall determine the focus of the inspection and organize special inspections in accordance with such factors as risk assessment of the medical security fund, reporting complaint leads and monitoring of medical security data.
26 The administrative department of medical security may conduct joint inspections in cooperation with the departments of health and health, Chinese medicine, market supervision and management, finance and public security.
the use of cross-regional medical security funds shall be examined by the administrative department of medical security designated by the administrative department of medical security at the same level.
Article 27 The administrative department for medical security may, when carrying out supervision and inspection, take the following measures: (1) enter the site for inspection; (2) ask the relevant personnel; (3) request the subject to provide documents and information related to the inspection matters, and make explanations and explanations; and (4) take records and recordings collect relevant information and information by video, photograph or reproduction; (5) seal information that may be transferred, concealed or lost; (6) employ third-party institutions and professionals such as qualified accounting firms to assist in the inspection; and (7) other measures prescribed by laws and regulations.
28 The administrative department of medical security may, in accordance with law, entrust organizations that meet the statutory conditions to carry out administrative law enforcement work on medical security.
29 of this article, supervision and inspection of the use of medical security funds shall be carried out, and the supervision and inspection personnel shall not be less than 2 persons, and law enforcement documents shall be presented.
supervision and inspection conducted by the administrative department of medical security, the subject under inspection shall cooperate, truthfully provide relevant information and information, and shall not refuse, obstruct or falsely report or conceal the report.
If a designated pharmaceutical institution is suspected of defrauding the expenditure of the medical security fund, the administrative department of medical security may, during the investigation, take measures such as increasing the frequency of supervision and inspection and strengthening the monitoring of expenses to prevent the loss from widening.
the designated pharmaceutical institution refuses to cooperate with the investigation, the medical security administrative department may, with the approval of the principal person in charge of the medical security administrative department, request the medical security agency to suspend the settlement of the medical security fund.
investigation, if the expenditure of the medical security fund is fraudulently obtained, it shall be dealt with in accordance with the provisions of Article 40 of these Regulations; if it is not the expenses of the medical security fund, it shall be settled in accordance with the provisions.
if the insured person is suspected of defrauding the medical security fund expenditure and refuses to cooperate with the investigation, the medical security administrative department may request the medical security agency to suspend the network settlement of medical expenses.
medical expenses that occur during the period of suspension of internet settlement shall be paid in full by the insured person.
investigation and is subject to fraudulent expenditure of the medical security fund, it shall be dealt with in accordance with the provisions of Article 41 of these Regulations;
Before the administrative department of medical security makes an administrative penalty or administrative processing decision on any violation of these Regulations, it shall listen to the parties' statements and arguments, and when making an administrative penalty or administrative treatment decision, it shall inform the parties that they have the right to apply for administrative reconsideration or initiate administrative proceedings in accordance with the law.
article 32 Administrative departments such as medical security, medical security agencies, accounting firms and other institutions and their staff shall not use the information or related information obtained or known in their work for purposes other than the supervision and management of the use of medical security funds, and shall not disclose, tamper with, destroy or illegally provide personal information and trade secrets to others.
article 33 The administrative department of medical security under the State Council shall establish a credit management system for designated medical institutions, personnel and so on, supervise and manage the classification of credit evaluation grades, incorporate the results of daily supervision and inspection, administrative punishment results, etc. into the national credit information sharing platform and other relevant information publicity systems, and implement disciplinary measures in accordance with the relevant provisions of the State.
34 The administrative department of medical security shall regularly announce to the public the results of supervision and inspection of the use of medical security funds, increase the exposure of illegal cases of the use of medical security funds, and accept social supervision.
Article 35 Any organization or individual shall have the right to report or complain about any violation of the law or regulation of the Medical Security Fund.
department of medical security shall open the channels for reporting complaints, deal with relevant complaints in a timely manner in accordance with the law, and keep the information of the whistleblower confidential.
to report the facts verified, and give the whistleblower a reward in accordance with the relevant provisions of the State.
Chapter IV Legal Responsibility Article 36 If a medical security agency has one of the following circumstances, the administrative department for medical security shall order it to make corrections and punish the persons in charge and other persons directly responsible according to law: (1) failure to establish and improve the business, financial, security and risk management system;
Article 37 The medical security agency shall, through forgery, alteration, concealment, alteration, destruction of medical documents, medical certificates, accounting vouchers, electronic information and other relevant funds