国务院办公厅转发国家体改委等四部委关于职工医疗保障制度改革扩

国办发（1996）16号
（May 5， 1996）
颁布日期：19960505 　实施日期：19960505 　颁布单位：国务院办公厅

“The Suggestions Regarding the Extension of the Scope of Experiment of the Reform of the Medicare System for Workers and Staff Members” （hereinafter referred to as the “Suggestions”） of the State Commission for Structural Reform， the Ministry of Finance， the Ministry of Labour and the Ministry of Public Health have been approved by the State Council and are hereby transmitted to you for earnest implementation.

The reform of the medic are system for workers and staff members constitutes an important component part of there form of the social security system in China. To advance the reform of the medic are system for workers and staff members so as to establish a new-type medical insurance system for workers and staff members， the State Council has decided to extend the scope of experiment by further selecting a number of cities where conditions are ripe nationwide in 1996 on the basis of the experiment of the reform of the medic are system for workers and staff members carried out in Zhenjiang City， Jiangsu Province and Jiujiang City， Jiangxi Province. The General Office of the State Council convened a “National Working Meeting on the Extension of the Scope of Experiment of the Reform of the Medicare System for Workers and Staff Members” from April 8 to 11 in Zhenjiang City. The “Suggestions” which have been formulated by the Commission and the three Ministries concerned on the basis of summing up the experiences gained in experiments in Zhenjiang， Jiujiang and other cities， extensive investigations and studies as well as widely seeking opinions， is a document which provides guidance in doing a good job of the extension of the scope of experiment of the reform of the medical insurance system for workers and staff members.

The reform of the medic are system for workers and staff members is an extremely complicated job which concerns the practical interests of the broad masses of workers and staff members， is highly policy-oriented and involves wide segments of society. People's governments of all the provinces （autonomous regions and municipalities） directly under the Central Government and the departments concerned shall earnestly implement the spirit of the “National Working Meeting on the Extension of the Scope of Experiment of the Reform of the Medicare System for Workers and Staff Members” and unfold the work of the extension of the scope of experiment of the reform in a positive and sound manner. To this end， the following requirements are hereby put forth：

1. People's Governments of all provinces （autonomous regions and municipalities） directly under the Central Government should pay great attention to this reform， earnestly strengthen leadership and practice the responsibility system of the leading member in charge by clearly designating a leading comrade in charge to be responsible for this work. They should unify ideas， enhance consciousness and confidence by organizing the study of the speech by State Councill or Peng Peiyun at the National Working Meeting on the Extension of the Scope of Experiment of the Reform of the Medicare System for Workers and Staff Members and the “Suggestions”， as well as the experiences of Zhenjiang City and Jiujiang City.

2. The work of the reform of the medic are system for workers and staff members of the cities undergoing the experiment shall be organized and carried out under the leadership of the provinces （autonomous regions and municipalities） directly under the Central Government. The people's government of every city undergoing the experiment should clearly designate a major leading comrade to be responsible for the work. The departments concerned of the State Council should step up guidance of the work of the cities undergoing the experiment. Cities engaging in the experiment should try their best to formulate practical and applicable proposals of implementation within six months on the basis of extensive investigation and study and meticulous predictions and calculations， according to the objectives and principles of the reform stipulated in the “Suggestions” and in the light of the actual conditions of the localities. The proposals shall be implemented upon examination and approval by the people's governments of the provinces （autonomous regions and municipalities） directly under the Central Government and be submitted to the Leading Group of the Experiment of the Reform of the Medicare System for Workers and Staff Members under the State Council for The record. Official launching of the experiment should be before the end of 1996.

3. All localities should make full use of such news and publicity media as broadcasting， television， newspapers， periodicals and magazines in extensive publicity and motivation to propagate the significance， objectives， principles， policies and approaches of this reform and to popularize the knowledge of medical insurance so as to win the understanding and support of the broad masses of workers， staff members and medical personnel of this reform.

4. The extension of the scope of experiment of the reform of the medic are system for workers and staff members shall earnestly follow the principle of territory. Organs at the central and provincial （autonomous regional and municipal）levels and their subordinate enterprises and institutions should all partake in the experiment of the reform of the medicare system for workers and staff members in the localities where they are located， and carry out the unified reform proposals of implementation of the localities.

Appendix： SUGGESTIONS OF THE STATE COMMISSION FOR STRUCTURAL REFORM， THE MINISTRY OF FINANCE， THE MINISTRY OF LABOUR AND THE MINISTRY OF PUBLIC HEALTH CONCERNING THE EXTENSION OF THE SCOPE OF EXPERIMENT OF THE REFORM OF THE MEDICARE SYSTEM FOR WORKERS AND STAFF MEMBERS（April 22， 1996）

The existing medic are system for workers and staff members （including free medical care and labour protection medical care） in China played an important role in the past in the protection of the health of workers and staff members， the promotion of economic growth and the maintenance of social stability. However， with the development of economy and deepening of the reform， problems have become increasingly prominent and a reform is bound to take place.

To advance the reform of the medicare system for workers and staff members， the State Council conducted an experiment of the reform of the medicare system for workers and staff members in Zhenjiang City， Jiangsu Province and Jiujiang City， Jiangxi Province starting from the first half year of l994， in accordance with the decision of the Third Plenary Session of the Fourteenth Central Committee of the Chinese Communist Party. During the one year or more， the experiment progressed smoothly and initial results have been achieved： a new mechanism for the raising of medical funds has been established； the level of basic medical care for workers and staff members has been raised； the momentum of over-growth of medical expenditure has been curbed； a push has been given to the internal reform of medical institutions； and a certain amount of experiences has been accumulated for further deepening the reform of the medicare system. In view of the fact that the reform of the medicare system for workers and staff members is an extremely complicated work which concerns the practical interests of the broad masses of workers and staff members， is highly policy-oriented and involves wide segments of society， and to gain further experience， in accordance with the requirements of gradual establishment of the medicare system based on the combination of the unifiedly raised social medical funds of the cities and towns and individual medical accounts and quickening the pace of reform of the medicare system during the “Ninth Five-Year Plan” period contained in the “Program of the Ninth Five-Year Plan of National Economic and Social Development and 2010 Perspective Goals of the People's Republic of China” adopted at the Fourth Session of the Eighth National People's Congress， the State Council has decided on the basis of the experiment of Zhenjiang City and Jiujiang City， to further select a number of cities where the conditions are mature to extend the scope of experiment of the reform of the medicare system for workers and staff members in a planned way and step by step.

1. Objective and Basic Principles of the Reform

The objective of the reform is to establish the social medical insurance system based on the combination of the unifiedly raised social medical funds and individual medical accounts and it will gradually cover all the laborers in cities and towns in keeping with the requirements of establishing the system of socialist market economy and raising of the health level of workers and staff members.

The basic principles of the establishment of the social medical insurance system for workers and staff members areas follows：

（1） Provision of basic medicare for all laborers in cities and towns to facilitate the shaping of a comprehensive social security system.

（2） The Level and mode of basic medicare have to be in keeping with the level of growth of social productivity in China and the capabilities of all sides involved to bear， with rational tripartite burden-sharing of the medical costs on the part of the State， units and workers and staff members.

（3） Combination of fairness with proficiency. Basic medicare treatment enjoyed by workers and staff members shall be appropriately linked with individual contributions to the society to mobilize the enthusiasm of workers and staff members.

（4） The Reform of the medicare system for workers and staff members should help reduce the social burden of enterprises and institutions， be conducive to the transformation of operations mechanism of the state-owned enterprises and the establishment of modern enterprise system.

（5） Establishment of restraining mechanisms on medical personnel and patients， promotion of deepening reform of medical institutions， strengthening of internal administration， upgrading of quality of medical service and improvement in efficiency， curbing of waste and establishment and perfection of rational compensation mechanism for medical institutions.

（6） Advancement of regional public health planning， promotion of socialization of medical institutions of enterprises and institutions in a planned way and step by step and gradual realization of optimal deployment and rational utilization of public health resources.

（7） A synchronous reform of the systems of free medical care and labour protection medical care shall be carried out in accordance with unified system and policy. The mode of raising medical insurance funds for workers and staff members and the basic structure of the funds should be uniform. Separate management and independent accounting can be practiced in the utilization of the funds.

（8） Separation of the government from the institutions shall be followed. The government departments in charge shall formulate policies， rules and regulations and standards； the collection， payment and operations of the medical insurance funds for workers and staff members shall be undertaken by the relatively independent social medical insurance institutions； the administration and supervision shall be enhanced so as to ensure rational utilization of the funds.

（9） Budgetary management shall be practiced with regard to the medical insurance funds for workers and staff members. The special funds shall be used for designated purposes and shall not be withdrawn for other purposes， nor shall the funds be used to balance financial budget.

（10） The principle of territory shall be followed in the establishment of the medical insurance system for workers and staff members. Organs at the central and provincial （autonomous regional， municipal） levels and their subordinate enterprises and institutions shall partake in the social medical insurance of the localities where they are located and follow uniform standards for fees and reform proposals of the localities.

2. Main Contents of the Extension of Experiment

（1） Raising of medical insurance funds for workers and staff members

Medical insurance funds for workers and staff members shall be contributed to mutually by the employer unit and individual workers and staff members.

The contribution by the employer unit： the rate of contribution by the employer unit shall be determined by the people's government of the city undergoing experiment with reference to the ratio of the actual expenditure of medical expenses for workers and staff members in the total wage bill of the workers and staff members of the city in the three preceding years. The employer unit shall contribute to the medical insurance funds according to the said rate for the workers and staff members of the unit.

Authorities empowered with examination and approval of the rate of contribution to the medical insurance funds for workers and staff members are： the rate of contribution not exceeding 10 percent of the total wage bill of workers and staff members shall be approved by the people's governments of provinces （autonomous regions， municipalities）directly under the Central Government； those exceeding 10 percent shall be submitted to the Ministry of Finance for approval upon examination by the people's governments of provinces （autonomous regions， municipalities） directly under the Central Government.

In accordance with the division of powers between institutions and finance， medical expenses of local units shall be borne by the finance of the locality， the employer units and individual workers and staff members， and the central finance shall give no subsidy. In determining the ratio of raising of resources for the medical insurance funds， the localities shall take into full account the requirements to ensure the basic medicare for workers and staff members and the burden-sharing capabilities of local finance， enterprises and institutions， and shall not compete with one another haphazardly.

Sources of contribution by the employer units： For administrative organs， institutions with full budget management and hospitals under ownership by the whole people with budget differentials control， the expenditure shall come from resources within the budget of the units； for other institutions with budget differentials control and institutions with budget control of independent revenue and expenditure， the expenditure shall be from the medical insurance funds drawn by the units； for serving workers and staff members of enterprises， the expenditure shall come from the welfare funds for workers and staff members， for those on honorary retirement and other retired personnel， the expenditure shall come from the labour protection insurance funds.

The collection of medical policy premiums paid by workers and staff members can be entrusted to banks to ensure timely collection. The base figure of premium payment to the medical insurance funds shall be calculated in strict accordance with the scope of statistics of the total wage bill of workers and staff members stipulated by the State Statistical Bureau. For the concealment in submitting the total wage bill， deliberate deferrals or refusal of payment of medical insurance premiums by units， the departments concerned in the cities undergoing experiment shall stipulate corresponding penalty provisions in accordance with law.

In principle， cities at the prefectural level shall be the units for unified raising of medical insurance funds for workers and staff members. For cities undergoing experiment with districts and counties （cities） under their jurisdiction having great discrepancies in the level of economic growth， there could be slight differences in the ratio of raising for the medical insurance funds. Specific measures shall be stipulated by the people's governments of the cities undergoing experiment.

Individual contributions by workers and staff members： to start with， the contribution of one percent of the worker's wage income shall be deducted by the employer unit from the wages for workers and staff members. The percentage shall be raised gradually in the future with economic growth and wage increase.

Workers and staff members in private-owned enterprises and Chinese workers and staff members in enterprises with foreign investment should take part in local social medical insurance. In principle， the mode of contribution and their medical treatment shall follow the uniform policies and standards of the localities.

Individual labourers in cities and towns may take part in social medical insurance. The rate of their medical policy premiums shall follow the average level of the localities and shall be borne entirely by the individuals.

（2） Opening of individual medical accounts for workers and staff members and setting up of the unifiedly raised social medical insurance funds

The medical policy premiums paid by individual workers and staff members and part of the medical insurance fees （generally not less than 50 percent） paid by the employer units for workers and staff members based on the calculations with the base figure of the worker's or staff member's wage， shall be put into individual medical accounts as special funds for designated purposes， to be used for the payment of medical expenses. For the portion to be put into individual medical accounts from the medical insurance fees paid by the units， different ratios can be determined according to age groups of workers and staff members.

The principal and interest of individual medical accounts shall be owned by individual workers and staff members which can only be used for medical expenditure， can be carried forward and inherited. However， no cash shall be drawn， nor can it be used for other purposes.

For balances in individual medical accounts of the year， the interest shall be calculated according to the interest rate for current deposit by urban and rural inhabitants； for the portion of relatively stable sedimental funds， the interest shall be calculated according to the interest rate for time deposit by urban and rural inhabitants in the corresponding period.

The balance of medical insurance fee paid by the employer unit for workers and staff members after deducting the amount put into individual medical accounts shall go to the unifiedly raised social medical insurance funds for concentrated accommodation and adjustment.

As a way of transition， with the approval of the municipal medical insurance institution， units originally having labour protection medicare can manage a portion of the unifiedly raised social medical insurance funds for internal accommodation with the units.

Payment of medical expenses by workers and staff members shall first be made from the individual medical accounts. When the individual medical account is exhausted， it shall be paid first by the worker or staff member himself （herself）。Calculated on a yearly basis， the portion of self-paid medical expense exceeding five percent of the individual's annual wage income shall be paid from the unifiedly raised social medical insurance funds. However， the individual still has to pay a certain percentage. The percentage of individual burden-sharing decreases as the medical expense increases； for the portion exceeding five percent of the individual's annual wage income but not more than RMB 5，000 yuan， the individual's burden-sharing shall be 10 to 20 percent； for the portion ranging from RMB 5，000 yuan to RMB 10，000 yuan， the individual's burden-sharing shall be 8 to 10 percent； for the portion exceeding RMB 10，000 yuan， the individual's burden-sharing shall be 2 to 5 percent. In the light of their practical conditions， people's governments of the cities undergoing experiment may determine the maximum ceiling for medical expenses to be covered by the unifiedly raised social medical insurance funds. For medical expenses exceeding the ceiling， cities undergoing experiment can Explore other solutions.

Medical expenses incurred from special categories of illnesses confirmed by the state and contracted by workers and staff members， or from birth control operation and its sequelae， shall be paid from the unifiedly raised social medical insurance funds.

（4） Matching reform and internal administration of medical institutions

Publicly run medical institutions which are non-profit social undertakings shall be planned and built by the people's governments of the localities. The capital construction and the purchase， installation and maintenance of large medical apparatuses shall be included in the capital construction plan and financial budget of the people's government at the same level， and overall arrangement be made. People's governments at various levels should increase their input in medical institutions with the growth of financial revenue. Financial responsibilities to be undertaken by government should be clearly defined and the scope and mode of supply of financial resources standardized. The revenue structure of medical institutions should be readjusted in a rational way with appropriate addition of items of medical fees which embody the value of the technical services of medical personnel and adjustment in the rate of those items， reducing the rate of charges for examinations with large medical apparatuses and the ratio of revenue from medicine in the gross income of medical profession on the basis of the rational use of medicine.

Workers and staff members receiving treatment in a number of designated medical institutions can purchase drugs from designated retail chemist's stores with prescriptions so as to urge the medical institutions to improve the quality of medical service.

The department of medical insurance administration in consultation with the department of public health， shall be responsible for the examination and designation of designated medical institutions in accordance with the principle of gradual taking shape and perfection of medical system at various levels and in consultation with the department in charge of medicine， shall be responsible for the examination and designation of designated retail chemist's stores.

Medical insurance institutions should sign contracts with designated units engaging in medical service and sale of medicine containing such contents as the scope， items and rates of basic medical insurance service and clearly defining responsibilities， rights and obligations. Expenses incurred from medical service and use of medicine exceeding the stipulations cannot be paid from the individual medical account， neither shall it be paid by the medical insurance institution. The mode of fixed amount settlement and payment of average medical service costs should be aggressively pursued on a trial basis.

The department of public health shall formulate technical standards for consultation and treatment； the department of public health in consultation with the department of finance and the department of medical insurance administration， shall compile a catalogue of medicine for reimbursement under medical insurance； the department of price control in consultation with the department of public health and the department of finance， shall fix rational rates to be charged for medical treatment at different grades which shall be revised at regular intervals.

Medical institutions should step up education of the medical personnel in professional morals and style， formulate and perfect necessary rules and regulations， standardize and guide conduct of medical treatment so as to reach the goal of rational diagnosis， treatment and excellent service.

Separate accounting shall be practiced with regard to the revenue and expenditure of medical service and those of sale of medicine by medical institutions. The mode of handing over the net income from sale of medicine to the department in charge at the higher level for unified administration and rational return should be practiced on a trial basis.

Government departments concerned and medical insurance institutions should conduct evaluation and inspection at regular intervals of the services of designated medical institutions and units engaging in sale of medicine. Rates of medical institutions shall be subject to the supervision of the department of price control and made public.

（5） Administration and supervision of medical insurance funds

Handling of medical insurance funds shall be the responsibility of the social medical insurance institutions. The principle of expenditure being determined by revenue， balance of revenue and expenditure with slight surplus should be adhered to； the special funds shall be used for designated purpose and shall not be used for other purposes， and security of the funds shall be ensured and realization of value maintenance and increment assured.

Medical insurance institutions shall establish scientific operation mechanism， upgrade the level of socialization of services and simplify procedures of reimbursement of medical costs and account settlement to make it convenient to the workers and staff members.

Medical insurance institutions shall formulate and perfect rules of examination and approval of the budget and final settlement of account， rules of accounting and auditing. The principle of practice of economy shall be followed in all items of expenditure and waste shall be eliminated. Administrative expenses shall be listed in the financial budget and be appropriated by the department of finance upon submission by the department in charge after examination and verification to the department of finance for examination and approval.

The departments of medical insurance administration shall be separated from the handling institutions. Establishment of the administrative departments shall be determined temporarily by the people's governments of the localities in the light of the actual conditions prevailing there.

Medical insurance supervisory bodies composed of representatives of government， representatives of employer units， representatives of trade unions and workers and staff members and representatives of specialists shall be formed to hear， at regular intervals， briefings by medical insurance institutions and medical institutions on the revenue and expenditure of medical insurance resources， operations and management and services which shall be made public. The auditing department shall regularly carry out auditing of medical insurance funds and the revenue and expenditure of insurance institutions.

3. Policies Concerning the Experiment

（1） Medical expenditure of honorary retirees and Red Army veterans shall be managed separately. One way is to bring it within the scope of the reform of the medical insurance system for workers and staff members with no opening of the individual medical accounts and no payment by the individual of medical policy premiums. Their medical expenses shall be paid from the unifiedly raised social medical funds. Medical insurance institutions can draw an amount equivalent to the average actually expended medical expenses in the three preceding years from the medical insurance funds for separate management and designated purposes. Overspending， if any， shall be settled through the original channel of financial resources. The other way which may be followed is that it is not included in the scope of the reform of the medical insurance system for workers and staff members and the medical costs shall be settled through the original channel of financial resources. Localities following this method shall deduct their medical expenses while making predictive calculations of the rate of premiums of the medical insurance funds for workers and staff members. Administration shall be strengthened and waste prevented whichever method is followed.

（2） For wounded and disabled revolutionary servicemen above Grade IIB， no individual medical account shall be opened， nor shall the individual pay medical policy premium. The medical cost shall be paid from the unifiedly raised social medical funds.

（3） Individual workers and staff members shall cease to pay medical policy premiums upon retirement. Those retired persons who have opened individual medical accounts， their medical expenses shall first be paid from the individual medical accounts； those who have not opened individual medical accounts or those whose individual medical accounts are exhausted， payments shall be made from the unifiedly raised social medical funds. However， the individual shall bear a portion of the cost； The ratio of burden-sharing of the retired persons individually shall be fifty percent of those paid by serving workers and staff members.

（4） All serving leading cadres shall participate in the reform of medical insurance system， join social medical insurance and observe uniform policies and rules. Appropriate accommodation can be provided for their medical consultation and hospitalization. In the meantime， administration shall be strengthened and waste prevented.

（5） Direct relatives and dependents supported by workers and staff members shall not be included in the scope of experiment of the reform of the medical insurance system for workers and staff members temporarily. For them， existing procedures shall continue to be followed.

（6） When the overburdening of medical expenses of low-income families and the workers and staff members who encounter difficulties in life adversely affects their basic life， the units in which they work shall give appropriate subsidies to them from the welfare funds.

（7） During the start-up stage of the reform of the medicare system， payment of medical policy premiums by individual workers and staff members shall in principle be made on the basis of pay rise. Expenditure of pay rise of enterprises shall be listed in the newly-added efficiency pay.

（8） Mutual-aid medical insurance for workers and staff members and commercial medical insurance shall be developed as a supplement to social medical insurance to satisfy medical requirements in addition to the basic medic are provided for by the state. However， the principle of voluntary participation and independent choice shall be adhered to.

（9） Measures of medical insurance for workers and staff members in rural and township enterprises shall be decided on the basis of study by municipal people's governments in accordance with the actual conditions of the localities.

4. Organization and Leadership of the Extension of Scope of Experiment

（1） The State Council shall form a leading group of the experiment of the reform of the medicare system for workers and staff members （in the form of office meeting）。 The leading group has under it an office which shall be located in the State Commission for Structural Reform with members dispatched from the Ministry of Finance， the Ministry of Labour and the Ministry of Public Health. The departments concerned under the State Council should work in close coordination to collectively do a good job of the experiment.

（2） The work of the reform of the medicare system for workers and staff members of the cities undergoing experiment shall be led， organized and carried out by the people's governments of provinces （autonomous regions， municipalities）directly under the Central Government. Each city undergoing experiment shall designate a responsible leading comrade to take charge of the work in person and strengthen leadership of the work of experiment in real earnest.

（3） Cities undergoing experiment should formulate implementation plans for the reform of the medicare system for workers and staff members of the localities in accordance with the “Suggestions” and in the light of the actual conditions of the localities. The implementation plans shall be submitted to the leading group of the experiment of the reform of the medicare system for workers and staff members of the State Council for the record upon examination and approval by the people's governments of provinces （autonomous regions and municipalities） directly under the Central Government.

（4） When the implementation plans for the reform of the medicare system for workers and staff members of the cities undergoing experiment are approved， extensive publicity and explanations shall be conducted by the cities undergoing experiment through the organs， people's associations， press units and other media directed at masses of workers and staff members for their acknowledgement， participation and support. In the meantime， training of the cadres of the government departments in charge and personnel of the social medical insurance institutions shall also be conducted to enhance their professional standards.