Order of the State Council of the People's Republic of China
No. 735
The Regulations on the Supervision and Administration of the Use of Medical Security Funds were adopted at the 117th executive meeting of the State Council on December 9, 2020. They are hereby promulgated and shall come into force on May 1, 2021.
Premier Li Keqiang
January 15, 2021
Regulations on the Supervision and Administration of the Use of the Medical Security Fund
Chapter One General Provisions
Article 1 In order to strengthen the supervision and management of the use of the medical security fund, ensure the safety of the fund, promote the effective use of the fund, and safeguard the citizens' legal rights and interests in medical security, these regulations are formulated in accordance with the "Social Insurance Law of the People's Republic of China" and other relevant laws and regulations.
Article 2 These Regulations apply to the use and supervision and management of medical insurance funds such as basic medical insurance (including maternity insurance) funds and medical assistance funds within the territory of the People's Republic of China.
Article 3 The use of the medical security fund adheres to centering on people's health, the level of protection is in line with the level of economic and social development, and the principles of legality, safety, openness, and convenience are followed.
Article 4 The supervision and management of the use of medical security funds shall be a combination of government supervision, social supervision, industry self-discipline and personal trustworthiness.
Article 5 The people’s government at or above the county level shall strengthen the leadership of the supervision and management of the use of medical security funds, establish and improve the supervision and management mechanism for the use of medical security funds and the law enforcement system for fund supervision and management, and strengthen the capacity building of supervision and management of the use of medical security funds to provide medical security. Provide guarantee for the supervision and management of fund use.
Article 6 The medical security administrative department of the State Council is in charge of the supervision and management of the use of medical security funds throughout the country.
Other relevant departments of the State Council shall be responsible for the supervision and management of the use of medical security funds within their respective responsibilities.
The medical security administrative department of the local people's government at or above the county level is responsible for the supervision and management of the use of medical security funds in its administrative area.
Other relevant departments of the local people's government at or above the county level shall be responsible for the supervision and management of the use of medical security funds within their respective responsibilities.
Article 7 The state encourages and supports the news media to conduct public welfare publicity of medical security laws, regulations and medical security knowledge, and conduct public opinion supervision over the use of medical security funds.
Publicity reports on medical security should be true and fair.
People’s governments at or above the county level and their medical security and other administrative departments shall solicit opinions in writing and hold symposiums to listen to the opinions of representatives of the People’s Congress, CPPCC members, and representatives of insured personnel on the use of medical security funds, unblock social supervision channels, 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 (hereinafter collectively referred to as medical institutions) and other units and medical and health industry associations shall strengthen industry self-discipline, regulate medical service behavior, promote industry norms and self-discipline, and guide the legal and rational use of medical security funds.
Chapter II Fund Use
Article 8 The use of the medical security fund shall conform to the payment scope prescribed by the state.
The payment scope of the medical security fund shall be organized and formulated by the medical security administrative department of the State Council in accordance with the law.
The 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 regions, and report to the medical security administrative department of the State Council for the record.
Article 9 The State shall establish and improve a unified national medical security handling management system, provide standardized and standardized medical security handling services, and achieve full coverage of provinces, cities, counties, towns (sub-districts), and villages (communities).
Article 10 The medical security agency shall establish a sound business, financial, security and risk management system, do a good job in service agreement management, expense monitoring, fund appropriation, remuneration review and payment, and regularly disclose the income of the medical security fund to the public , Expenditures, balances, etc., subject to social supervision.
Article 11 The medical security agency shall establish a collective bargaining and consultation mechanism with the designated medical institution, reasonably determine the medical security fund budget amount and the time limit for the designated medical institution’s medical security fund, and cooperate with the designated medical institution according to the needs of public health protection and management services. Institutions negotiate and sign service agreements, regulate medical service behaviors, and clarify violations of service agreements and their responsibilities.
The medical security agency shall promptly announce to the public the list of designated medical institutions that have signed service agreements.
The medical security administrative department shall strengthen supervision of the conclusion and implementation of service agreements.
Article 12 The medical security agency shall promptly settle and allocate the medical security fund in accordance with the provisions of the service agreement.
Designated medical institutions shall provide medical services in accordance with regulations, improve service quality, rationally use medical security funds, and safeguard citizens' health rights.
Article 13 If a designated medical institution violates the service agreement, the medical security agency may urge it to perform the service agreement, suspend or not approve the payment according to the service agreement, recover the violation fee, suspend the relevant responsible personnel or the department involved in medical security The medical services used by the fund until the service agreement is terminated; the designated medical institution and its related responsible personnel have the right to make statements and defenses.
If the medical security agency violates the service agreement, the designated medical institution has the right to request correction or request the medical security administrative department to coordinate processing and urge rectification, and may also apply for administrative reconsideration or file an administrative lawsuit in accordance with the law.
Article 14 The designated medical institution shall establish an internal management system for the use of medical security funds, and a special agency or personnel shall be responsible for the management of the use of medical security funds, and establish a sound assessment and evaluation system.
The designated medical institution shall organize training on the relevant systems and policies of the medical security fund, regularly check the use of the medical security fund of the unit, and promptly correct the irregular use of the medical security fund.
Article 15 The designated medical institution and its staff shall implement the real-name medical treatment and drug purchase management regulations, verify the medical security certificates of the insured persons, provide reasonable and necessary medical services in accordance with the diagnosis and treatment specifications, and truthfully issue the expense receipts and related related documents to the insured persons Materials, do not disassemble hospitalization, stay in bed, do not violate diagnosis and treatment regulations, excessive diagnosis and treatment, excessive examination, disintegration of prescriptions, over-prescription, repeated prescriptions, no repeated charges, over-standard charges, disaggregated item charges, and no exchange of drugs and medical consumables , Diagnosis and treatment items and service facilities, shall not induce or assist others to seek medical treatment or purchase drugs under false names or false names.
The designated medical institution shall ensure that the expenses paid by the medical security fund meet the prescribed payment scope; except for special circumstances such as emergency treatment and rescue, providing medical services beyond the payment scope of the medical security fund shall obtain the consent of the insured person or his close relatives and guardians .
Article 16 Designated medical institutions shall keep financial accounts, accounting vouchers, prescriptions, medical records, treatment inspection records, cost details, records of the entry and exit of medicines and medical consumables, and other materials in accordance with regulations, and transmit medical security funds in a timely and accurate manner through the medical security information system. Use relevant data to report to the medical security administrative department the information required for the supervision and management of the use of the medical security fund, to disclose information such as medical expenses and fee structure to the public, and to accept social supervision.
Article 17 The insured person shall take the medical insurance certificate to seek medical treatment, purchase medicine, and take the initiative to show it for inspection.
The insured person has the right to request the designated medical institution to truthfully issue expense receipts and related materials.
Participants shall properly keep their medical insurance certificates to prevent others from using them under false names.
If it is necessary to entrust others to purchase drugs for special reasons, the identity certificates of the principal and the trustee shall be provided.
Insured persons shall enjoy medical insurance treatment in accordance with regulations and shall not enjoy it repeatedly.
Participants have the right to request medical security agencies to provide medical security consulting services, and to make suggestions for improvements in the use of medical security funds.
Article 18 During the use of the medical security fund, medical security and other administrative departments, medical security handling agencies, designated medical institutions and their staff shall not accept bribes or obtain other illegal income.
Article 19 Insured persons shall not use the opportunity of enjoying the medical insurance benefits to resell drugs, accept the return of cash, in kind, or obtain other illegal benefits.
The designated medical institution shall not provide convenience for the insured persons to take advantage of the opportunity of enjoying the medical insurance benefits to resell drugs, accept the return of cash, in kind, or obtain other illegal benefits.
Article 20: Medical security agencies, designated medical institutions and other units and their staff and insured personnel shall not use forgery, alteration, concealment, alteration, or destruction of medical documents, medical certificates, accounting vouchers, electronic information, etc. Information, or fictitious medical service items, etc., to defraud medical security funds.
Article 21 The medical security fund is earmarked for its exclusive use, and no organization or individual may embezzle or misappropriate it.
Chapter III Supervision and Administration
Article 22: Departments such as medical security, health, traditional Chinese medicine, market supervision and management, finance, auditing, public security, etc. shall coordinate and cooperate with each other, establish communication and coordination, case transfer and other mechanisms, and jointly supervise and manage the use of medical security funds. jobs.
The medical security administrative department shall strengthen the supervision of medical service activities and medical expenses included in the payment scope of the medical security fund, standardize the medical security handling business, and investigate and deal with illegal use of the medical security fund in accordance with the law.
Article 23 The medical security administrative department of the State Council is responsible for formulating service agreement management measures, standardizing, simplifying, and optimizing medical institutions' designated application, professional evaluation, and negotiation procedures, and preparing and regularly revising service agreement templates.
The medical security administrative department of the State Council formulates service agreement management measures and shall listen to the opinions of relevant departments, medical institutions, industry associations, the public, experts, etc.
Article 24 The medical security administrative department shall strengthen information exchange and sharing with relevant departments, innovate supervision and management methods, promote the use of information technology, establish a nationally unified, efficient, compatible, convenient and safe medical security information system, and implement big data Real-time dynamic intelligent monitoring, and strengthen the management of the whole process of using shared data to ensure the security of shared data.
Article 25 The medical security administrative department shall determine the focus of inspection and organize special inspections based on factors such as the risk assessment of the medical security fund, the clues of reporting complaints, and the monitoring of medical security data.
Article 26 The medical security administrative department may conduct joint inspections with the departments of health, traditional Chinese medicine, market supervision and management, finance, and public security.
The use of cross-regional medical security funds shall be inspected by the medical security administrative department designated by the common higher-level medical security administrative department.
Article 27 The medical security administrative department may take the following measures to implement supervision and inspection:
(1) Enter the site for inspection;
(2) Ask relevant personnel;
(3) Require the inspected object to provide documents related to the inspection items, and provide explanations and explanations;
(4) Collect relevant information and materials by recording, audio recording, video recording, photographing or copying;
(5) Sealing up the materials that may be transferred, concealed or lost;
(6) Hiring qualified accounting firms and other third-party institutions and professionals to assist in the inspection;
(7) Other measures stipulated by laws and regulations.
Article 28 The medical security administrative department may entrust an organization that meets the statutory requirements to carry out the administrative law enforcement of medical security according to law.
Article 29 To carry out supervision and inspection of the use of medical security funds, the number of supervisors and inspectors shall not be less than two, and the law enforcement certificates shall be presented.
When the medical security administrative department conducts supervision and inspection, the subject to be inspected shall cooperate, provide relevant materials and information truthfully, and shall not refuse or obstruct inspection or make false or concealed reports.
Article 30 If a designated medical institution is suspected of defrauding medical security fund expenditures, during the investigation period, the medical security administrative department may take measures such as increasing the frequency of supervision and inspection and strengthening cost monitoring to prevent the loss from expanding.
If the designated medical institution refuses to cooperate with the investigation, the medical security administrative department may request the medical security agency to suspend the settlement of the medical security fund upon the approval of the principal person in charge of the medical security administrative department.
After investigation, it is found that the expenditure of the medical security fund by fraud shall be dealt with in accordance with the provisions of Article 40 of these Regulations; if the expenditure is not the expenditure of the medical security fund by fraud, the settlement shall be made in accordance with the regulations.
If an insured person is suspected of defrauding medical security fund expenditures and refuses to cooperate with the investigation, the medical security administrative department may request the medical security agency to suspend the online settlement of medical expenses.
The medical expenses incurred during the suspension of online settlement shall be paid in full by the insured persons.
After investigation, it is found that the expenditure of the medical security fund by fraud shall be dealt with in accordance with the provisions of Article 41 of these Regulations; if the expenditure is not the expenditure of the medical security fund by fraud, the settlement shall be made in accordance with the regulations.
Article 31 The medical security administrative department shall hear the party’s statement and defense before making an administrative penalty or administrative handling decision for a violation of these regulations; if an administrative penalty or an administrative handling decision is made, the party shall be notified of the legal right to apply for administrative reconsideration or file an administrative review. The right to administrative litigation.
Article 32: Medical security and other administrative departments, medical security agencies, accounting firms, and other institutions and their staff shall not use the data or related information of the subject or related information obtained and known during work for the supervision and management of the use of the medical security fund For purposes other than those, the personal information and business secrets of the parties concerned shall not be disclosed, altered, destroyed, or illegally provided to others.
Article 33 The medical security administrative department of the State Council shall establish a credit management system for designated medical institutions, personnel, etc., supervise and manage classified and classified according to credit evaluation levels, and incorporate daily supervision and inspection results, administrative punishment results, etc. into the national credit information sharing platform and other Relevant information publicity system implements punishment in accordance with relevant state regulations.
Article 34 The medical security administrative department shall regularly announce the results of the supervision and inspection of the use of medical security funds to the public, increase exposure to illegal cases of the use of medical security funds, and accept social supervision.
Article 35 Any organization or individual has the right to report and complain about violations of the medical security fund.
The medical security administrative department shall unblock the reporting and complaint channels, deal with the related reports and complaints in a timely manner in accordance with the law, and keep the informant's information confidential.
For reports verified to be true, the reporter will be rewarded in accordance with relevant state regulations.
Chapter IV Legal Liability
Article 36: If a medical security agency has any of the following circumstances, the medical security administrative department shall order it to make corrections and impose sanctions on the directly responsible persons in charge and other directly responsible persons according to law:
(1) Failure to establish a sound business, financial, security and risk management system;
(2) Failure to perform duties such as service agreement management, expense monitoring, fund appropriation, treatment review and payment;
(3) The income, expenditure, and balance of the medical security fund are not regularly disclosed to the public.
Article 37: Where a medical security agency defrauds medical security fund expenditures by forging, altering, concealing, altering, destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant materials or fabricating medical service items, etc., The medical security administrative department shall order the refund and impose a fine of two to five times the amount of fraudulently obtained, and the directly responsible person in charge and other directly responsible persons shall be punished according to law.
Article 38 If a designated medical institution has any of the following circumstances, the medical security administrative department shall order it to make corrections and may interview the relevant person in charge; if it causes losses to the medical security fund, it shall be ordered to return, and the amount of damage caused shall be more than double The following fines; if it refuses to make corrections or causes serious consequences, the designated medical institution shall be ordered to suspend the medical services of the relevant responsible department for 6 months to 1 year involving the use of the medical security fund; for violations of other laws and administrative regulations, the relevant competent department shall be subject to law deal with:
(1) Decompose hospitalization and stay in bed;
(2) Excessive diagnosis and treatment, over-examination, decomposition of prescriptions, over-prescribing, re-prescribing or providing other unnecessary medical services in violation of diagnosis and treatment regulations;
(3) Repeated charges, over-standard charges, and disaggregated item charges;
(4) Exchange of medicines, medical consumables, diagnosis and treatment items and service facilities;
(5) To provide convenience for the insured persons to take advantage of the opportunity of enjoying the medical insurance treatment to resell drugs, accept the return of cash, in kind, or obtain other illegal benefits;
(6) Include medical expenses that are not covered by the medical security fund payment into the medical security fund settlement;
(7) Other illegal acts that cause losses to the medical security fund.
Article 39 If a designated medical institution has any of the following circumstances, the medical security administrative department shall order it to make corrections and may interview the relevant person in charge; if it refuses to make corrections, a fine of 10,000 yuan to 50,000 yuan shall be imposed; other violations Laws and administrative regulations shall be handled by the relevant competent departments according to law:
(1) Failure to establish an internal management system for the use of medical security funds, or no special agency or personnel responsible for the management of the use of medical security funds;
(2) Failing to keep financial accounts, accounting vouchers, prescriptions, medical records, treatment inspection records, expense details, records of entering and exiting warehouses of medicines and medical consumables, etc., as required;
(3) Failing to transmit data on the use of medical security funds through the medical security information system in accordance with regulations;
(4) Failing to report to the medical security administrative department the information required for the supervision and management of the use of the medical security fund;
(5) Failing to disclose medical expenses, expense structure and other information to the public in accordance with regulations;
(6) Except for special circumstances such as emergency treatment and rescue, providing medical services beyond the scope of payment by the medical security fund without the consent of the insured person or his close relatives or guardians;
(7) Refuse to supervise and inspect by administrative departments such as medical security or provide false information.
Article 40: Where designated medical institutions defraud medical security fund expenditures through the following methods, the medical security administrative department shall order the refund and impose a fine of 2 times to 5 times the amount defrauded; order the designated medical institutions to suspend the relevant responsible departments for more than 6 months1 The medical services used by the medical security fund under the age of the following year, until the service agreement is terminated by the medical security agency; if there is a qualification, the relevant competent authority shall revoke the qualification according to law:
(1) Inducing or assisting others to seek medical treatment or purchase drugs under false names, provide false certification materials, or collude with others to issue false expense documents;
(2) Forging, altering, concealing, altering, or destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant materials;
(3) Fictitious medical service projects;
(4) Other acts of defrauding medical security fund expenditures.
For the purpose of defrauding the medical security fund, a designated medical institution has performed one of the acts specified in Article 38 of these Regulations, causing losses to the medical security fund, and shall be dealt with in accordance with the provisions of this article.
Article 41: Individuals in one of the following circumstances shall be ordered by the medical security administrative department to make corrections; if they cause losses to the medical security fund, they shall be ordered to return; if they belong to the insured persons, their online settlement of medical expenses shall be suspended for 3 to 12 months :
(1) Handing over my medical insurance certificate to others for false use;
(2) Repeatedly enjoy medical insurance treatment;
(3) Taking advantage of the opportunity of enjoying medical insurance treatment to resell drugs, accept returning cash, in-kind, or obtain other illegal benefits.
For the purpose of defrauding the medical security fund, an individual performs one of the acts specified in the preceding paragraph and causes the loss of the medical security fund; or uses someone else’s medical security certificate to seek medical treatment or purchase medicine under the false name; or through forgery, alteration, concealment, alteration, or destruction If medical documents, medical certificates, accounting vouchers, electronic information and other relevant materials or fictitious medical service items are used to defraud medical security fund expenditures, in addition to the provisions of the preceding paragraph, the medical security administrative department shall also defraud more than twice the amount Fines below 5 times.
Article 42: Where medical security and other administrative departments, medical security agencies, designated medical institutions and their staff accept bribes or obtain other illegal income, the illegal income shall be confiscated, and the relevant responsible persons shall be punished according to law; violation of other laws and administrations Regulations shall be dealt with by the relevant competent department according to law.
Article 43: If a designated medical institution violates the provisions of these Regulations and causes major losses to the medical security fund or other serious adverse social impacts, its legal representative or main person in charge shall be prohibited from engaging in management activities of the designated medical institution within 5 years, and the relevant department shall grant the payment according to law Sanction.
Article 44 Anyone who violates the provisions of these Regulations and embezzles or misappropriates the medical security fund shall be ordered by the medical security and other administrative departments to recover; if there are illegal gains, the illegal gains shall be confiscated; the directly responsible persons in charge and other directly responsible persons shall be granted according to law Sanction.
Article 45 The returned fund shall be returned to the original medical security fund special financial account; the illegal income of fines and confiscated shall be turned over to the State Treasury in accordance with the law.
Article 46: Where medical security and other administrative departments, medical security agencies, accounting firms, and other institutions and their staff disclose, tamper with, damage, or illegally provide personal information or business secrets to others, the person in charge shall be directly responsible And other directly responsible personnel shall be punished in accordance with law; violations of other laws and administrative regulations shall be dealt with by relevant competent departments in accordance with law.
Article 47: Staff of administrative departments such as medical security who abuse their power, neglect their duties, or engage in malpractice for personal gains in the supervision and management of the use of medical security funds shall be punished in accordance with law.
Article 48 Anyone who violates these regulations and constitutes a violation of public security management shall be given public security management penalties according to law; if a crime is constituted, criminal responsibility shall be investigated according to law.
Anyone who violates these regulations and causes losses to relevant entities or individuals shall be liable for compensation in accordance with the law.
Chapter 5 Supplementary Provisions
Article 49 The supervision and management of the use of medical security funds such as large-amount medical expenses subsidies for employees and medical subsidies for civil servants shall be implemented with reference to these regulations.
The use of resident serious illness insurance funds shall be implemented in accordance with relevant state regulations, and the medical security administrative department shall strengthen supervision.
Article 50 These regulations shall come into force on May 1, 2021.