Regulations on the Supervision and Administration of the Use of Health Care Funds

Chapter I General ProvisionsArticle 1 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 the medical security fund, ensure the safety of the fund, promote the effective use of the fund and safeguard the legitimate rights and interests of citizens' medical security.Article 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.Article 3 The use of medical security funds shall be guided by the people's health, the level of protection shall be in line with the level of economic and social development, and the principles of legality, safety, openness and access to the people shall be followed.Article 4 The use of the medical security fund shall be combined with government supervision, social supervision, industry self-discipline and personal trustworthy.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 for the supervision and administration 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.Article 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.The 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. Other relevant 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 publicity on medical security laws, regulations and knowledge of medical security, and to supervise 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 the insured persons on the use of the medical security fund, open channels of social supervision, and encourage and support all sectors of society to participate in the supervision of the use of the medical security fund.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.Chapter II The use of fundsthe use of medical security funds shall conform to the scope of payment prescribed by the State.The scope of payment of medical security funds shall be organized and formulated by the administrative department of medical security under 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 the formulation of 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 medical security management system, 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 the operational, financial, security and risk management systems, do a good job in the management of service agreements, cost monitoring, fund allocation, treatment audit 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, in accordance with the need to safeguard public health needs and manage services, negotiate and sign service agreements with designated medical institutions to regulate the conduct of medical services and clarify the violation of service agreements and their responsibilities. The medical security agency shall promptly publish to the society the list of designated medical institutions that have signed service agreements. The administrative department 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 medical 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 fulfill 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; the fixed-point medical institutions and their related responsible personnel shall have the right to make statements and plead. If a medical security agency violates a service agreement, the designated medical institution shall have the right to request correction or to request the administrative department of medical security to coordinate the handling and supervision of rectification, or it may apply for administrative reconsideration or initiate administrative proceedings in accordance with the law. Article 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. The designated medical institutions shall organize and carry out 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 Fixed-point medical 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, shall not decompose the hospitalization or hospitalization, and shall not violate the diagnosis and treatment Over-diagnosis, over-examination, decomposition of prescriptions, over-prescription, repeated prescription of drugs, may not repeat charges, over-standard charges, decomposition project charges, may not exchange drugs, medical supplies, medical treatment items and service facilities, may not induce, assist others to falsely seek medical treatment, purchase drugs. The designated medical institution shall ensure that the expenses paid by the medical security fund conform to the prescribed scope of payment, and those who provide medical services outside the scope of payment of the medical security fund, except in special circumstances such as emergency or rescue, shall obtain the consent of the insured persons or their next of kin or guardians. Article 16 A fixed-point pharmaceutical institution shall, in accordance with the provisions, keep financial accounts, accounting vouchers, prescriptions, medical records, medical examination records, expense details, records of access to medicines and medical supplies, etc., transmit the relevant data on the use of the medical security fund in a comprehensive and accurate manner through the medical security information system, report to the medical security administrative department the information necessary for the supervision and management of the use of the medical security fund, disclose to the public information on medical expenses, cost structure and so on, and accept social supervision. Article 17 The insured persons shall seek medical treatment, purchase medicines and take the initiative to present them for examination with their own medical security certificates. The insured persons shall have the right to request the fixed-point pharmaceutical institutions to truthfully issue expense documents and related information. The insured person shall properly keep his medical security certificate and prevent others from using it under the pretation. If it is necessary for special reasons to entrust another person to purchase medicine on his behalf, the identity of the principal and the trustee shall be provided. Insured persons shall enjoy medical security treatment in accordance with the provisions and shall not be repeated. Insured persons have 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 may 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. The designated pharmaceutical institutions shall not facilitate the transfer of medicines by the insured persons to take advantage of their medical security treatment and accept the return of cash, in kind or other illegal benefits. Article 20 Medical security agencies, fixed-point 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. Article 21 No organization or individual may appropriate or misappropriate funds earmarked for medical security funds. Chapter III Supervision and Management Article 22 Departments of 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. The administrative department of 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 shall listen to the opinions of relevant departments, medical institutions, trade associations, the public and experts in formulating measures for the administration of service agreements. Article 24 The administrative department for 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. Article 25 The administrative department for 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. Article 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 of 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) require the subject to be examined to provide documents and information related to the inspection matters, and make explanations and explanations; (4) collect relevant information and information by recording, recording, video recording, taking photographs or copying; (5) sealing information that may be transferred, concealed or lost; (6) engaging qualified accounting firms and other third-party institutions and professionals to assist in the inspection; and

(7) Other measures prescribed by laws and regulations. Article 28 Medical security