Suggestions on Perfecting the Medical Security System for Ordinary College and University Students of This Municipality

上海市医疗保险局、上海市教育委员会、上海市财政局关于完善本市普通高等院校学生医疗保障制度若干意见的通知

Promulgating Date: 03/15/2007

Effective Date: 04/01/2007

颁布机关: 上海市医疗保险局; 上海市教育委员会; 上海市财政局

颁布时间: 03/15/2007

实施时间: 04/01/2007

With a view to perfecting the medical security system of this Municipality, practically guaranteeing the basic medical treatment for the students of colleges and universities, and enlarging the coverage of the medical security, we hereby put forward the following suggestions on perfecting the medical security system for ordinary college and university students of this Municipality:

    为了健全本市医疗保障体系，切实保障普通高等院校学生的基本医疗，扩大医疗保障覆盖范围，现就完善本市普通高等院校学生医疗保障制度提出若干意见如下:

I.Objects of security

The full-time undergraduates, high-vocational or high professional training students, and non-on-the-job graduate students that take studies for regular higher academic education (hereinafter referred to as undergraduates) in various colleges and universities, and scientific researching institutions (hereinafter referred to as colleges) in this Municipality.

       一、保障对象

    本市各类高等院校、科研院所(以下统称“院校”)中接受普通高等学历教育的全日制本科学生、高职高专学生以及非在职研究生(以下统称“大学生”)。

II. Modes of security

The hospitalization (including stay-in-hospital observation in emergency observation ward, similarly hereinafter) and clinical treatment of the undergraduates for serious diseases including uraemia dialysis, malignant tumor, mental disease, haemophilia, aplastic anemia (hereinafter generally referred to as clinical serious diseases) shall follow the municipality-level centralized overall management while the ordinary clinical and emergency treatments follow the approaches of " Fixed fund allocation from finance, management by school, special funds for special purposes and apportionment for over expenditures"

       二、保障方式

    大学生的住院(包括急诊观察室留院观察,下同)和门诊重症尿毒症透析、恶性肿瘤、精神病、血友病、再生障碍性贫血治疗(以下统称“门诊大病”)实行市集中统筹管理;普通门急诊实行“财政定额拨款、学校管理、专款专用、超支分担”的方式。

III. Administrative departments and units

1. The municipal medical insurance bureau, the municipal education commission and the municipal finance bureau shall, in accordance with their respective duties, take over the management work of undergraduates' medical security of this Municipality in an earnest way.

2. The executive organ of the medical insurance takes charge of the management on medical treatment, examination, verification and settlement of medical expenses within the scope of the medical security for the undergraduates in hospitalization and clinical treatment for serious diseases in this Municipality.

3. The colleges take charge of the management on medical treatments and the settlement of medical expenses for their own undergraduates in ordinary clinical and emergency treatments and provide assistance in relevant management on medical treatments for their own undergraduates in hospitalization and clinical treatment of serious diseases.

       三、管理部门和单位

    (一)市医保局、市教委和市财政局根据各自职责,做好本市大学生医疗保障的管理工作。

    (二)医疗保险经办机构负责本市大学生住院和门诊大病医疗保障的就医管理及医疗费用审核结算等经办业务。

    (三)各院校负责本院校大学生普通门急诊的就医管理及医疗费用报销等业务,并协助做好本院校大学生住院及门诊大病就医管理的相关工作。

IV. Arrangement and management of funds

The undergraduates' medical security fund consists of two parts: the medical overall fund for hospitalization and clinical treatment of serious diseases (hereinafter referred to as overall fund) and the subsidiary fund for ordinary clinical emergency treatment (hereinafter referred to as subsidiary fund).

1. The overall fund shall be verified and allocated by the municipal finance to the municipal executive organ of medical insurance at the ration of 50 yuan per student on a yearly basis, which is used in a unified way and settled at the end of each year with the residual to offset the allocation next year.

2. The subsidiary fund shall be verified and allocated by the municipal finance to colleges through original channels at the ration of 45 yuan per student on a yearly basis, which is settled at the end of each year with the residual accumulated for next year's use while the over-expenditures shall be borne by the municipal finance and colleges on a fifty-fifty basis.

The collection ration of overall fund, the fixed ration of subsidiary fund, and the replenishment ratio on over-expenditures shall be properly adjusted in accordance with the economic and social development, and the utilization of funds.

The undergraduates' medical security fund shall be managed strictly, examined and verified in a standardized way, accounted separately, used for specified purposes, not be embezzled , and supervised and inspected by the finance and auditing departments.

       四、资金筹措和管理

    大学生医疗保障资金由住院及门诊大病医疗统筹资金(以下简称“统筹资金”)和普通门急诊医疗补助资金(以下简称“补助资金”)两部分组成。

    (一)统筹资金由市财政按每生每年度50元的标准核拨至市医疗保险经办机构统筹使用,年终清算,结余资金抵减下一年度经费。

    (二)补助资金由市财政按每生每年度45元的标准通过原渠道核拨至各院校,年终清算,年度结余滚存使用,超支由市财政补助50%,院校承担50%。

    对统筹资金筹措标准、补助资金定额标准及超支补助比例,根据经济社会发展和资金使用情况适时调整。

    大学生医疗保障资金必须严格管理、规范审核、单独核算、专款专用,不得挪作他用,并接受财政、审计部门的监督检查。

V. Treatments of security

1. The starting payment amount for medical expenses incurred in each hospitalization of the undergraduate, in compliance with relevant provisions on medical security for undergraduates of this Municipality shall be set as follows: 300 yuan for Grade Three Hospitals, 100 yuan for Grade Two Hospitals and 50 yuan for Grade One Hospitals. The medical expenses equal to or below the starting payment amount shall be borne by the undergraduate himself/herself, and the medical expenses above the starting payment mount shall be paid from the overall fund.

2. The medical expenses incurred by the undergraduates in ordinary clinical treatment for serious disease in compliance with relevant provisions on medical security for undergraduates of this Municipality shall be totally paid from the overall fund.

3. For medical expenses incurred by the undergraduates in ordinary out – patient and emergency treatment, in compliance with relevant provisions on medical security for undergraduates of this Municipality, the colleges shall pay at a rate of not lower than 90% of medical expenses for the clinical treatment within the college, or at a rate of not lower than 80% of medical expenses for the clinical and emergency treatment outside the college respectively , and the balance shall be borne by the undergraduate himself/herself.

       五、保障待遇

    (一)对大学生每次住院发生的符合本市大学生医疗保障有关规定的医疗费用,设立起付标准,具体为:三级医院300元;二级医院100元;一级医院50元。起付标准及以下部分医疗费用由个人负担,起付标准以上部分医疗费用由统筹资金支付。

    (二)大学生因门诊大病发生的符合本市大学生医疗保障有关规定的医疗费用,全部由统筹资金支付。

    (三)大学生发生的符合本市大学生医疗保障有关规定的普通门急诊医疗费用,由各院校分别按院校内门诊医疗费用不低于90%、院校外普通门急诊医疗费用不低于80%的比例支付,其余部分由个人负担。

VI. Medical treatment and the settlement

1. The hospitalization and treatment of serious diseases of the undergraduates in this Municipality takes place at the designated hospitals (the hospitalization incurred by emergency treatment shall be excluded), which are determined by the colleges out of the designated institutions within the scope of basic medical insurance of this Municipality. The undergraduate shall take the medical treatment upon the settlement certificate for hospitalization or clinical serious disease treatment printed by the executive organ of medical insurance, and the medical expenses of hospitalization and clinical treatment of serious diseases incurred in compliance with relevant provisions on medical security for undergraduates of this Municipality shall be first charged to an account of the designated hospitals then applied to the local district/county executive organ of medical insurance for settlement.

2. When the undergraduate needs hospitalization in other provinces or cities in case of emergency or needs hospitalization or a clinical treatment of serious diseases in other provinces or cities for illness or other reasons within the period of school suspension, he/she shall turn to the local designated medical institutions of medical insurance. The incurred medical expenses shall be first paid by the undergraduate himself/herself, and then be reimbursed by the executive organ of medical insurance of this Municipality upon the application of colleges in a unified way within six months from the date of discharge from hospital or accomplishment of the treatment.

3. The undergraduates' ordinary clinical treatment in this Municipality is provided at the colleges' dispensaries or at other hospitals through transfer. The medical expenses of clinic treatment of the undergraduates incurred at the designated medical organ through transfer by the colleges' dispensaries, the medical expenses incurred from emergency treatment in this Municipality or in other provinces and cities, and the medical expenses of ordinary clinical treatment incurred in other provinces and cities for illness within the period of school suspension, shall be first paid by the undergraduate, and then reimbursed after his/her return to school in accordance with the provisions.

       六、就医和结算

    (一)大学生在本市住院和门诊大病实行定点医疗(急诊住院除外),定点医院由各院校在本市基本医疗保险定点医疗机构范围内合理确定。大学生凭医疗保险经办机构印制的住院或门诊大病结算凭证就医,发生的符合本市大学生医疗保障有关规定的住院和门诊大病医疗费用,由定点医院记账后,向所在区县医疗保险经办机构申报结算。

    (二)大学生在外省市发生急诊住院,或因病等休学期间需要在外省市住院或门诊大病医疗时,应到所在地的医疗保险定点医疗机构就医。发生的医疗费用由其本人垫付后,在出院或治疗后6个月内,由院校统一到本市医疗保险经办机构申请报销。

    (三)大学生在本市普通门诊实行院校医务部门就诊和转诊医疗。大学生经院校转诊在本市定点医疗机构发生的门诊医疗费用、在本市或外省市因急诊发生的医疗费用,以及因病等休学期间在外省市发生的普通门诊医疗费用,由其本人垫付后,回院校按规定报销。

VII. Colleges' specific responsibilities

The Colleges shall do the following works well in a practical manner:

1. To appoint a leader who takes charge of the medical security management for their own undergraduates, designate the specific administrative department, and set up a coordination and management mechanism between relevant departments.

2. To enhance the construction of inner-college medical dispensaries. The colleges in which the conditions are available shall try their best to set up medical dispensaries and the colleges in which the conditions are not available shall entrust the nearby community public health service centers, etc. to ensure the undergraduates' ordinary clinical and emergency medical treatment.

3. To set up a mutual medical fund for the poor undergraduates, bring the medical mutual aid into the College subsidiary scope of aiding the poor in education and provide assistance to the students with the difficulties in bearing the self-borne medical expenses (including those medical expenses needed for serious disease treatment but not within the payment scope of the medical insurance).

4. To continuously bring the functions of commercial insurance into full play, and encourage the undergraduates to participate in commercial insurance programs on their own initiatives to further improve the medical security level.

       七、院校具体职责

    各院校应切实做好以下工作:

    (一)明确本院校大学生医疗保障管理工作的分管领导,指定具体管理部门,并建立相关部门协调管理机制。

    (二)加强院校内医务部门建设,有条件的院校应尽量开设医务部门,不具备条件的院校应通过委托邻近社区卫生服务中心等途径,确保大学生普通门急诊医疗。

    (三)建立大学生医疗帮困互助金,或将医疗帮困纳入院校帮困助学的补助范围,对个人自负医疗费(包括治疗大病重病所需非医保支付范围内的医疗费)有困难的学生给予帮助。

    (四)继续发挥商业保险的作用,鼓励大学生自愿参加商业保险,进一步提高医疗保障水平。

VIII. Others

1. The scope of available medicines for undergraduates' medical security, the management on medical treatment, and the service facilities shall be carried out with the reference to the relevant provisions on town/township working staff's basic medical insurance of this Municipality. The colleges shall respectively formulate the detailed management regulations on the medical treatment, reimbursement method of medical expenses for undergraduates in clinical and emergency treatment.  

2. The implementation rules on undergraduates' medical security shall be separately formulated by the municipal medical insurance bureau jointly with the municipal education commission and the municipal finance bureau.

These Suggestions shall become effective as of April 1, 2007.

Shanghai Municipal Medical Insurance Bureau

Shanghai Municipal Education Commission

Shanghai Municipal Finance Bureau

March 15, 2007

       八、其他

    （一）大学生医疗保障的用药范围、诊疗项目和服务设施等的管理，参照本市城镇职工基本医疗保险有关规定执行。大学生普通门急诊的具体就医管理和医疗费用报销方式等，由各院校自行制定。

    （二）大学生医疗保障的实施细则，由市医保局会同市教委、市财政局另行制定。

    本意见自2007年4月1日起施行。

    上海市医疗保险局

    上海市教育委员会

    上海市财政局

    二○○七年三月十五日