Measures of Tianjin Economic-Technological Development Area on Medical Insurance

(Adopted at the meeting of the Administrative Commission of Tianjin Economic Technological Development Area on October 30, 1996; amended at the 24th meeting of chairmen of the Administrative Commission of Tianjin Economic Technological Development Area on December 19, 2001)

Article 1 [ purpose and basis ] These Measures are formulated with a view to ensuring the basic medical treatment of the staff and workers and the retired persons of Tianjin Economic-Technological Development Area ( hereinafter referred as "TEDA" ), in accordance with the "Decision of the State Council Regarding the Establishment of Cities and Towns Staff's and Workers' Basic Medical Insurance System", "Provisions of Tianjin Municipality on Basic Medical Insurance for Urban Staff and Workers" and relevant laws, regulations and rules and in light of the actual situation of TEDA.

Article 2 [basic principles] The basic medical insurance level shall match the economic development level of the Municipality; the management by registered site shall be practiced; TEDA employers and their staff and workers are obliged to take part in the basic medical insurance; the basic medical insurance premium is jointly borne by the employers and their staff and workers; the basic medical insurance shall practice combination of the overall fund and personal accounts; and the medical insurance fund shall adhere to the principle that expenditure is determined by revenue, both ends meet and it is raised and employed in a consolidated way.

Article 3 [application scope] The following employers and personnel shall apply to these Measures:

1. the State owned enterprises, urban collective enterprises, joint-stock companies, private enterprises in urban areas and their staff and workers ( including farmers serving as contracted workers, temporary jobbers and seasonal workers) as well as the retired persons;

2. foreign-funded enterprises, enterprises with investment from Hong Kong, Macao and Taiwan, foreign establishments in Tianjin, establishments of Hong Kong, Macao and Taiwan in Tianjin and their staff and workers and retired persons with the Chinese mainland citizenship;

3. non-governmental and non-enterprise units, their staff and workers and retired persons;

4. State organs, social organizations, institutions and their staff and workers and retired persons.

Article 4 [insurance coverage] The medical insurance shall compensate the medical expenses of the staff and workers and retired persons who suffer normal diseases or non-industrial injuries. The medical insurance coverage includes the following items:

1. medicine expenses;
2. examination expenses;
3. treatment expenses;
4. hospitalization expenses; and
5. funeral expenses of staff and workers.

Article 5 [insurance requirements] The newly established units shall go through the insurance registration procedures at TEDA social insurance agency within 30 days as of the date of going through the industrial and commercial registration procedures, and pay the basic medical insurance premium as prescribed.

The newly recruited staff and workers of employers are required to have health check-ups at the medical treatment units designated by TEDA social insurance agency before participating the medical insurance; those who suffer special diseases ( Category I, and Category II ) should open files on the diseases at TEDA social insurance agency for the record.

Article 6 [insurance premium calculation and collection] The basic medical insurance premium shall be collected every month according the following stipulations:

1. Employers shall pay the basic medical insurance premium at a rate of 9 % of their staff and workers' monthly average wages in the previous year;

2. Employers shall pay the premium of the outpatient (emergency) large amount medical expenses insurance at a rate of 1 % of their staff and workers' monthly average wages in the previous year;

3. Staff and workers shall pay the basic medical insurance premiums at a rate of 1 % of their personal monthly average wages in the previous year.

Article 7 [premium charging bases] Employers shall pay the basic medical insurance premium timely and fully. The minimum wages standard for Tianjin municipality shall be the base for the basic medical insurance premium of the staff and workers whose monthly average wages in the previous year are below the minimum wages standard for Tianjin municipality. The part exceeding the 300 % of the monthly average wages in the previous year of staff and workers in Tianjin municipality shall not serve as the base for payment of basic medical insurance premium.

Any staff and workers whose monthly average wages in the previous year can not be determined shall pay the basic medical insurance premium with the monthly average wages in the previous year of staff and workers in Tianjin municipality as the base.

Article 8 [calculation of personal accounts] The personal accounts shall be calculated as follows:

1. The basic medical insurance premium paid by the staff and workers shall be put into their individual personal accounts; the basic medical insurance premium paid by employers shall be allocated into the personal accounts of their staff and workers separately at the following two rates: 3.5 % of their staff and workers monthly wages that they pay the premium for those under 45 full years old and 4.5 % for those above 45 full years old;

2. An amount from the medical overall fund equal to 8 % of the personal total sum of the basic old age pensions of the retired persons shall be allocated into their personal accounts;

3. The personal accounts may be carried over to and used in the nest year; the personal accounts may be transferred along with the staff and workers in case of their work relationship changes, be transferred to the local social insurance institution in case that the staff and workers leave Tianjin municipality for a new place, be cleared so that the balance in the account be returned in case that there is no social insurance institution there; the personal accounts may be cleared so that the balance in the account be returned in case that the staff and workers go to settle abroad; and in case that the staff and workers quit from the insurance as a result of natural death, their balance in the personal accounts shall be inherited by their heirs, in case of no heir, be transferred to the overall fund of the basic medical insurance after settlement of the debts.

Article 9 [payments on personal accounts] The payments on personal accounts shall cover the following items:

1. the medical expenses incurred on outpatient (emergency) treatment at the designated medical institutions;

2. the medical expenses under the starting criterion of disbursement;

3. the medical expenses above the starting criterion and under the maximum amount of disbursement to be borne by the individuals;

4. the medical expenses above the maximum amount of disbursement to be borne by the individuals.

The measures on disbursement of expenses to purchase medicine at the designated retail drugstores shall be formulated separately.

Article 10 [overall fund] The overall fund is used to disburse the medical expenses of the staff and workers holding work posts and the retired persons who are hospitalized and the medical expenses on special diseases which require long term outpatient medical treatment. The special diseases shall be determined by the administrative department of labor and social security of Tianjin Municipality.

1. The starting criterion of disbursement from the overall fund for the staff and workers who are hospitalized in the year shall be 10 % of the monthly average wages in the previous year of staff and workers in Tianjin municipality. The starting criterion of disbursement from the overall fund for the staff and workers who are hospitalized as of the second time in one year shall be 3 % of the monthly average wages in the previous year of staff and workers in Tianjin municipality. There shall be different starting criterions of disbursement for medical institutions of different grades. The maximum amount of disbursement from the overall fund for hospitalization shall be four times the monthly average wages in the previous year of staff and workers in Tianjin municipality.

2. The medical expenses under the starting criterion of disbursement shall be borne by the inpatients themselves; the part of their expenses above the starting criterion and under the maximum amount of disbursement shall be disbursed from the overall fund separately at a proportion of 85 % for staff and workers and at 90 % for retired persons.

3. The starting criterion of disbursement of expenses on part of the special diseases (Category I) which require long term outpatient treatment from the overall fund is the same starting criterion of disbursement for the first time hospitalization at hospitals of Grade 2; and the maximum amount and proportion of disbursement are the same for hospitalization. The starting criterion of disbursement of expenses on part of the special diseases (Category II) which require long term outpatient treatment from the overall fund is two times that of the starting criterion of disbursement of expenses on the special diseases (Category I); and the maximum amount and proportion of disbursement are the same for hospitalization.

4. The expenses of staff and workers on the infectious diseases of Category A shall be disbursed fully from the overall fund of the basic medical insurance; proper favors shall be given to the sufferers of part of other infectious diseases.

5. The disbursement from the overall fund of the basic medical insurance shall cover the following items:

(1). The inpatient medical expenses;
(2). The medical expenses incurred within the seven days on emergency, rescue and stay for observation prior to hospitalization;
(3). The outpatient medical expenses on kidney dialysis, anti-rejection therapy after kidney transplantation, malignant tumors' radioactive therapy, chemical therapy and pain-easing therapy ( including by Chinese traditional medical therapies) as well as diabetes, cor pulmonale, lupus erythematosus, hemiparalysis and mental diseases; and
(4). Other medical expenses to be disbursed from the overall fund as prescribed.

Article 11 [scope of refusal of disbursement] The medical expenses incurred under the following cases shall be excluded from disbursement from the basic medical insurance fund:

1. Those who receive medical treatment at non-designated medical institutions and purchase medicine at non-designated drugstores;

2. Those whose medical treatments received and medicines purchased are not in conformity with the treatment items, standards of medical service facilities and the medicine categories covered by the basic medical insurance;

3. Those whose injuries and sequelae resulting from traffic accidents, medical accidents and other liability accidents;

4. Those who receive medical treatments on body injuries caused by their personal illegal acts or injuries and illness as a result of suicide, intended self-injury and excessive use of alcoholic beverages;

5. The expenses to continue hospitalization of those who have definitely or basically recovered through hospitalization but refuse to leave the hospital while they may; and
6. Other cases of refusal of disbursement as prescribed by the State and Municipal provisions.

Article 12 [checkup criterion] The medical expenses of the staff and workers and the retired persons shall be checked up and disbursed in accordance with the "Category of Treatment Items and Standard of Medical Service Facilities of Tianjin Urban Staff and Workers' Basic Medical Insurance" and the relevant regulations. The social insurance agency shall not disburse the expenses that do not tally with the stipulations.

Article 13 [ service and management] The basic medical insurance shall practice the management of designated medical institutions and designated drugstores.

The hospitalization and transfer of medical consultation and treatment out of the municipality shall be subject to examination and approval.

The staff and workers of Tianjin's establishments resident at other places, those who carry out field operations or are out of the municipality on work errands and the retired persons who dwell out of the municipality shall abide by relevant provisions in case of receiving medical treatment or hospitalization when they are ill.

Article 14 [outpatient (emergency) large amount expenses] The part exceeding 600-5,000 yuan of the accumulative medical expenses of the staff and workers and the retired persons in a year shall be subsidized with the outpatient (emergency) large amount expenses at a proportion of 80 %.

Large amount expenses on outpatient (emergency) treatments incurred by staff and workers are paid with their own money first; then the employers collect and sort out all the materials including the valid receipts under the starting criterion, prescriptions, case history, the details of medicine used and submit them to the social insurance agency based on different category and within the prescribed time; and the expenses shall, upon checkup and approval, be disbursed.

Article 15 [standard of funeral expenses] The standard of funeral expenses of staff and workers shall abide by the relevant State provisions.

Article 16 [validity of medical insurance] The validity of the staff and workers' medical insurance for staff and workers holding their posts starts from the month following the month when they are insured and ends in the month following the month when their insurance stops; for the retired persons, it starts from the month they take the old age pension and ends in the month they die; the staff and workers who have suspended their insurance as a result of unemployment or other reasons may continue to use the fund in their personal accounts to disburse their medical expenses till running out when they are injured or ill.

Article 17 [additional medical insurance and medical aid fund] Employers may insure the additional medical insurance for their staff and workers to cover the part of the medical expenses to be borne by their staff and workers, retired persons themselves in addition to the basic medical insurance of their staff and workers. The part of the fund for additional medical insurance may be itemized in the costs in case that it is within 4 % of the total wages of their staff and workers.

TEDA adopts measures to aid those who have to pay large amounts of medical expenses. Staff and workers and retired persons pay the aid fund for those who have to pay large amounts of medical expenses at a rate of three yuan/per month /per person to the social insurance agency to disburse the part above the maximum amount of disbursement under basic medical insurance till 150,000 yuan in the total amount at a proportion of 80 %; while the three yuan/per month /per person on the part of the retired persons shall be paid with the overall fund. The rates for the payment of the aid fund and disbursement level shall be examined and determined as prescribed by the administrative department of labor and social security of Tianjin Municipality year after year.

TEDA adopts measures to aid those who have to pay extra-large amounts of medical expenses to disburse the part above150,000 yuan in the total amount of medical expenses of staff and workers and retired persons; the specific measures shall be formulated separately.

Article 18 [time limit] The staff and workers who have paid the premium of medical insurance fully for five years are entitled to the medical insurance treatment after their retirement.

Article 19 [other]

1. The medical treatment for those retired cadres with honors shall remain unchanged and abide by relevant provisions.

2. The medical treatment for revolutionary wounded and disabled servicemen above Grade 2 Class B shall remain unchanged; the medical expenses shall be disbursed with original channels of funds.

Article 20 [interpretation right] TEDA Administrative Commission shall be responsible to interpret these Measures.

Article 21 [implementation date] These Measures shall be implemented as of January 1, 2002.