(May 11, 1999)
Article 1: In accordance with The State Council's Decision on Establishing Basic Medical Insurance System for Urban and Township Employees (State Council No. 44 ), this Regulation is promulgated to strengthen and standardize the administration of designated medical institutions for urban and township employees with basic medical insurance.
Article 2: The designated medical institutions in this Regulation refers to those medical institutions which pass examination by overall local labor and social security administrative departments and are confirmed by social insurance agencies to provide medical services to urban and township employees covered by basic medical insurance.
Article 3: The principles for the examination and selection of designated medical institutions are as follows: the medical institution should be convenient for an insured seeking medical services and be convenient for administration; consideration must be given to both specialized hospitals and general hospitals, to both Western medicines and traditional Chinese medicines, and with an emphasis on health centers at the community level; the collection of medical resources should be optimized; the utilized efficiency of medical resources should be improved, the medical service costs should be reasonably controlled, and the quality of medical service should be enhanced.
Article 4: The following types of medical institutions that have obtained the approval of medical administrative authorities and obtained an Operating License for Medical Institution, as well as qualified military medical institutions that have obtained the approval of military authorities to provide civilian services, may apply to be a designated medial institution:
(1) general hospitals, hospitals of traditional Chinese medicine, hospitals combining Western medicines with traditional Chinese medicine, hospitals of minority medicines, and specialized hospitals;
(2) centralized hospitals, health centers at township level, neighborhood health centers, and health centers for women and children;
(3) comprehensive outpatient department, specialized department, departments of traditional Chinese medicine, departments combining Western medicines with traditional Chinese medicine, and departments of minority medicine;
(4) clinics, clinics of traditional Chinese medicine, clinics of minority medicine, health clinics, and medical stations;
(5) specialized health institutes (clinics, stations); and,
(6) medical service institutions at the community level which have obtained the approval of health departments at the prefecture level and above.
Article 5: The designated medical institution shall meet the following criteria:
(1) meet the regional overall allocation plan of local medical institutions;
(2) meet the examination standard of medical institutions;
(3) observe relevant laws, regulations and standards on medical service; have an established and perfected a sound management system on medical service;
(4) strictly follow the price policies on medical services and drugs stipulated by pricing authorities at the national, provincial (autonomous regions and municipal cities) level; pass the inspection and examination of pricing departments;
(5) strictly follow relevant policies concerning the basic medical insurance system for urban and township employees, establish appropriate internal management mechanisms corresponding to the administration system over the basic medical insurance system, and have the necessary management staff and equipment.
Article 6: A medical institution that wants to provide medical services to urban and township employees with basic health insurance should apply in writing to the overall local labor and social security department and provide the following materials:
(1) duplicate original of operation license;
(2) list of large-scale medical instruments/equipment;
(3) the previous year's revenue/expense report and amount of outpatient services and inpatient services (including number of outpatients, average expenses of each outpatient service, number of inpatients, average length of stay, average expenses of each inpatient when discharged from hospital, average daily medical expenses of each inpatient, etc.), as well as the capability of providing services for medical insurance system;
(4) certifying materials which show the medical institute meets the evaluation standards of a medical institute;
(5) certifying materials from drug administration departments and pricing departments which prove its qualifications;
(6) other materials stipulated by the labor and social security departments.
Article 7: Labor and social security departments shall examine the qualifications of a medical institution according to its application and various materials provided. A license qualifying a medical institution as a designated medical institution shall be issued to those which pass the examination and those qualified will be publicized for the insured's reference.
Article 8: The insured will select one of designated medical institutions and report such selection to the employer who will collect and submit a report to overall local social insurance agency, which will confirm the insured's selection.
Article 9: The specialized medical institutions and medical institutions of traditional Chinese medicine (including medical institutions combining traditional Chinese medicine with Western medicine, as well as medical institutions of minority medicine) that have obtained the qualification of a designated medical institution may be chosen as the designated medical institution of the overall locality.
In addition to the specialized medical institutions and medical institutions of traditional Chinese medicine that have obtained the qualification of a designated medical institution, the insured usually can select from three to five medical institutions at various levels, among those which should be included are at least one to two medical institutions at the lowest level (including first-class hospitals, as well as various health centers, inpatient department, clinics, medical stations, and community health stations). Localities with higher management ability may enlarge the numbers of designated medical institutions from which the insured may select.
Article 10: The insured may request to change his designated medical institution after one year, and should report his intention to the overall local social security agency which will handle the procedures for the change.
Article 11: The social insurance agencies must sign agreements with designated medical institutions concerning the people who will be covered by the service, service scope, service contents, service quality, the settlement measures, as well as examination and control of medical expenses, etc., so as to make clear the responsibilities, rights and duties of both parties. The period of validity of such agreements is one year. No matter which party violates the agreement, the other party has the absolute right to terminate the agreement, but it must inform the other party and insured three months in advance, and file a report with the overall local labor and social security bureau.
Article 12: The insured shall obtain medical services in a designated medical institution. The insured may buy drugs in either the designated medical institution, or may fill the prescription in a designated retail drugstore, at his own choice.
Except for emergency treatment and first aid, the expenses incurred by the insured outside of the selected designated medical institution shall not be covered by basic medical insurance funds.
Article 13: The percentage of medical expenses paid by the insured can vary according to the level of designated medical institution, thus the insured is encouraged to obtain medical services in the designated medical institution at the lowest level.
The overall local labor and social security department will decide the specific percentage paid by the insured at different levels of designated medical institutions, as well as the specific administrative rules concerning transfer between departments and hospitals.
Article 14: A designated medical institution should have full-time (part-time) administrative staff, who will assist the social insurance agencies to fulfil the administrative tasks. The medical expenses of an insured covered by basic medical insurance should have separate accounts. The medical expenses of the insured covered by basic medical insurance and related information should be timely and accurately reported to social security agencies.
Article 15: Social insurance agencies should strengthen their examination of the medical expenses incurred by insureds at designated medical institutions. Designated medical institutions shall provide relevant materials and account [expense] lists concerning the medical expenses of the insured.
Article 16: The social insurance agencies should, in accordance with related policies and stipulations on basic medical insurance as well as their agreements with the designated medical institutions, fully pay the expenditures on time. The expenditures occurred beyond the related stipulations will not be paid by the social insurance agencies.
Article 17: The labor and social security departments should organize health departments and price departments to strengthen their examination and inspection over the services and management of designated medical institutions. As to those designated medical institutions violating the policies and stipulations, the labor and social security departments should order them to correct the violations, or notify the health authorities for criticism, or cancel its designated qualification.
Article 18: The application form and qualification license sample of a designated medical institution should be promulgated by the Ministry of Labor and Social Security.
Article 19: The labor and social security departments of various provinces (autonomous regions and municipal cities) may organize health departments and other related departments to promulgate detailed implementing rules on the basis of this Regulation.
Article 20: This Regulation comes into force upon promulgation.
For Application Form for Designated Medical Institutions (Sample), Please click here