中英对照2021医疗保障基金使用监督管理条例.docx

RegulationontheSupervisionand/AdministrationoftheUseofHealthcareSecurityFundsDocumentNumber：OrderNo.735oftheStateCouncilofthePeople'sRepublicofChinaAreaofLaw:FundsHealthCare1.evelofAuthority：AdministrativeRegulationsIssuingAuthority：StateCouncilDateIssued：01-15-2021EffectiveDate:05-01-2021Status:EffectiveOrderoftheStateCouncilofthePeople'sRepublicofChina(No.735)TheRegulationontheSupen,isionandAdministrationoftheUseofHealthcareSecurityFunds,asadoptedatthe117tlexecutivemeetingoftheStateCouncilonDecember9,2020,isherebyissued,andshallcomeintoforceonMay1,2021.Premier:LiKeqiangJanuary15,2021RegulationontheSupervisionandAdministrationoftheUseofHealthcareSecurityFundsChapterIGeneralProvisions中华人民共和国国务院令（第735号）医疗保障基金使用监督管理条例已经2020年12月9日国务院第117次常务会议通过，现予公布，自2021年5月1日起施行。总理李克强2021年1月15日医疗保障基金使用监督管理条例第一章总则Article 1 ThisRegulationisdevelopedinaccordancewith第一条为了加强医疗保障基金使用监督管理，保theprovisionsoftheSocialInsuranceLawofthePeople'sRepublicofChinaandotherapplicablelawsforthepurposesofstrengtheningthesupervisionandadministrationoftheuseOfhealthcaresecurityfunds,guaranteeingthesecurityoffunds,enhancingtheefficientuseoffunds,andprotectingcitizens'lawfulrightsandinterestsintermsofhealthcaresecurity.Article 2 ThisRegulationshallapplytotheuseofhealthcaresecurityfundssuchasfundsforbasicmedicalinsurance(includingmaternityinsurance),andmedicalassistancefundswithintheterritoryofthePeople'sRepublicofChinaandthesupervisionandadministrationthereof.Article 3 Theuseofhealthcaresecurityfundsshallcenteronthepeople'shealth,guaranteethatthesecurityleveliscommensuratewiththelevelofeconomicandsocialdevelopment,andfollowtheprinciplesoflegality,security,opennessandconvenienceforthepeople.Article 4 Thesupervisionandadministrationoftheuseofhealthcaresecurityfundsshallintegrategovernmentregulation,socialsupervision,industryself-regulationandpersonalintegrity.Article 5 Thepeople'sgovernmentatorabovethecountylevelshallstrengthentheleadershipofthesupen,isionandadministrationoftheuseofhealthcaresecurityfunds,establishandimprovethemechanismforthesupen,isionandadministrationoftheuseofhealthcaresecurityfundsandfund障基金安全，促进基金有效使用，维护公民医疗保障合法权益，根据中华人民共和国社会保险法和其他有关法律规定，制定本条例。第二条本条例适用于中华人民共和国境内基本医疗保险（含生育保险）基金、医疗救助基金等医疗保障基金使用及其监督管理。第三条医疗保障基金使用坚持以人民健康为中心，保障水平与经济社会发展水平相适应，遵循合法、安全、公开、便民的原则。第四条医疗保障基金使用监督管理实行政府监管、社会监督、行业自律和个人守信相结合。第五条县级以上人民政府应当加强对医疗保障基金使用监督管理工作的领导，建立健全医疗保障基金使用监督管理机制和基金监督管理执法体制，加强医疗保障基金使用监督管理能力建设，为医疗保障基金使用监督管理工作提供保障。supervisionandadministrationlawenforcementsystem,strengthentheconstructionofcapabilityforthesupen,isionandadministrationoftheuseofhealthcaresecurityfunds,andprovideguaranteeforthesupervisionandadministrationoftheuseofhealthcaresecurityfunds.第六条 国务院医疗保障行政部门主管全国的医疗保障基金使用监督管理工作。国务院其他有关部门在各自 职责范围内负责有关的医疗保障基金使用监督管理工作。Article 6 ThehealthcaresecurityadministrativedepartmentoftheStateCouncilshalltakechargeofthesupen,isionandadministrationoftheuseofhealthcaresecurityfundsnationwide.OtherrelevantdepartmentsoftheStateCouncilshallberesponsibleforthesupervisionandadministrationoftheuseofhealthcaresecurityfundswithinthescopeoftheirrespectiveduties.县级以上地方人民政府医疗保障行政部门负责本行政区域 的医疗保障基金使用监督管理工作。县级以上地方人民政 府其他有关部门在各自职责范围内负责有关的医疗保障基 金使用监督管理工作。Thehealthcaresecurityadministrativedepartmentofthelocalpeoplesgovernmentatorabovethecountylevelshallberesponsibleforthesupervisionandadministrationoftheuseofhealthcaresecurityfundswithinitsadministrativeregion.Otherrelevantdepartmentsofthelocalpeople'sgovernmentatorabovethecountylevelshallberesponsibleforthesupervisionandadministrationoftheuseofhealthcaresecurityfundswithinthescopeoftheirrespectiveduties.第七条国家鼓励和支持新闻媒体开展医疗保障法律、法规和医疗保障知识的公益宣传，并对医疗保障基金 使用行为进行舆论监督。有关医疗保障的宣传报道应当真 实、公正。Article 7 Thestateencouragesandsupportsnewsmedia'spublicityonhealthcaresecuritylawsandregulationsandhealthcaresecurityknowledgeforpublicinterest,andshalloverseetheuseOfhealthcaresecurityfundsbypublicopinions.Thehealthcaresecuritypublicityandreportsshallbetrueandimpartial.People'sgovernmentsatorabovethecountylevelandtheirhealthcaresecurityandotheradministrativedepartmentsshallsolicittheopinionsofdeputiestothepeople'scongress,CPPCCmembers,andrepresentativesoftheinsured,amongothers,ontheuseofhealthcaresecurityfundsbysuchmethodsassolicitingopinionsinwritingandholdingsymposiums,keepsocialsupervisionchannelsunimpeded,andencourageandsupporttheparticipationofallsectorsofsocietyinthesupervisionoftheuseofhealthcaresecurityfunds.Medicalinstitutionsanddrugdistributionentities(hereinaftercollectivelyreferredtoas“medicalinstitutions,)andotherentitiesaswellasmedicalandhealthindustryassociationsshallstrengthenindustryself-regulation,regulatemedicalservices,promoteindustrialstandardizationandself-regulation,anddirectthelawfulandreasonableuseofhealthcaresecurityfunds.ChapterIIUseofFundsArticle 8 Healthcaresecurityfundsshallbeusedwithinthescopeofpaymentprovidedforbythestate.ThescopeofpaymentOfhealthcaresecurityfundsshallbedeterminedbythehealthcaresecurityadministrativedepartmentoftheStateCouncilinaccordancewiththelaw.Thepeople'sgovernmentofaprovince,autonomousregion,ormunicipalitydirectlyundertheCentralGovernmentshall,accordingtothepowerandproceduresprescribedbytheslate,supplementthespecificitemsandstandardsforthepaymentof县级以上人民政府及其医疗保障等行政部门应当通过书面征求意见、召开座谈会等方式，听取人大代表、政协委员、参保人员代表等对医疗保障基金使用的意见，畅通社会监督渠道，鼓励和支持社会各方面参与对医疗保障基金使用的监督。医疗机构、药品经营单位（以下统称医药机构）等单位和医药卫生行业协会应当加强行业自律，规范医药服务行为，促进行业规范和自我约束，引导依法、合理使用医疗保障基金。第二章基金使用第八条医疗保障基金使用应当符合国家规定的支付范围。医疗保障基金支付范围由国务院医疗保障行政部门依法组织制定。省、自治区、直辖市人民政府按照国家规定的权限和程序，补充制定本行政区域内医疗保障基金支付的具体项目和标准，并报国务院医疗保障行政部门备案。healthcaresecurityfundswithinitsadministrativeregion,andreportthemtothehealthcaresecurityadministrativedepartmentoftheStateCouncilforrecordation.therefor.Article 9 Thestateshallestablishandimproveanationalunifiedhealthcaresecuritymanagementsystem,providestandardizedandregulatedhealthcaresecurityservices,andrealizethefullcoverageofhealthcaresecurityinprovinces,cities,counties,towns(sub-districts)andvillages(communities).Article 10 Healthcaresecurityagenciesshallestablishandimprovetheirbusiness,financial,securityandriskmanagementrules,effectivelyconductsuchworkasserviceagreementmanagement,costmonitoring,funddisbursement,benefitexaminationandpayment,andonaperiodicalbasis,releasetothepublicthereceipts,expenditures,balanceandotherinformationonhealthcaresecurityfunds,andacceptsocialsupervision.Article 11 Healthcaresecurityagenciesshallestablishacollectivenegotiationandconsultationmechanismwithdesignatedmedicalinstitutions,reasonablydeterminethebudgetamountandtimelimitforthedisbursementofhealthcaresecurityfundsofdesignatedmedicalinstitutions,andnegotiateandsignserviceagreementswithdesignatedmedicalinstitutionsasrequiredforsafeguardingpublichealthandmanagementservicestoregulatemedicalsen,icesandspecifytheviolationsofserviceagreementsandtheliability第九条国家建立健全全国统一的医疗保障经办管理体系，提供标准化、规范化的医疗保障经办服务，实现省、市、县、乡镇（街道）、村（社区）全覆盖。第十条医疗保障经办机构应当建立健全业务、财务、安全和风险管理制度，做好服务协议管理、费用监控、基金拨付、待遇审核及支付等工作，并定期向社会公开医疗保障基金的收入、支出、结余等情况，接受社会监督。第H条医疗保障经办机构应当与定点医药机构建立集体谈判协商机制，合理确定定点医药机构的医疗保障基金预算金额和拨付时限，并根据保障公众健康需求和管理服务的需要，与定点医药机构协商签订服务协议，规范医药服务行为，明确违反服务协议的行为及其责任。HealthcaresecurityagenciesshalLinatimelymanner,announcetothepublicthelistofdesignatedmedicalinstitutionswithwhichtheyhavesignedserviceagreements.Healthcaresecurityadministrativedepartmentsshallstrengthenthesupervisionofsuchcircumstancesastheconclusionandperformanceofserviceagreements.Article 12 Healthcaresecurityagenciesshall,asagreeduponinserviceagreements,conductthesettlementofanddisbursehealthcaresecurityfundsinatimelymanner.Designatedmedicalinstitutionsshallprovidemedicalservicesaccordingtoapplicableprovisions,enhancesen,icequality,reasonablyusehealthcaresecurityfunds,andprotectcitizens'healthrightsandinterests.Article 13 Whereanydesignatedmedicalinstitutionviolatestheserviceagreement,thehealthcaresecurityagencymayurgeittoperformtheserviceagreement,andasagreeduponintheserviceagreement,suspendorrejectthedisbursementoffunds,recoverexpensesincurredinviolationofanyprovision,andsuspendtheprovisionofmedicalservicesinvolvingtheuseofhealthcaresecurityfundsbytherelevantliablepersonorthedepartmentwhereheorsheworks,andevenrescindtheserviceagreement.Thedesignatedmedicalinstitutionanditsrelevantliablepersonshavetherighttomakestatementsandarguments.Whereanyhealthcaresecurityagencyviolatestheserviceagreement,thedesignatedmedicalinstitutionhastherightto医疗保障经办机构应当及时向社会公布签订服务协议的定点医药机构名单。医疗保障行政部门应当加强对服务协议订立、履行等情况的监督。第十二条医疗保障经办机构应当按照服务协议的约定，及时结算和拨付医疗保障基金。定点医药机构应当按照规定提供医药服务，提高服务质量，合理使用医疗保障基金，维护公民健康权益。第十三条定点医药机构违反服务协议的，医疗保障经办机构可以督促其履行服务协议，按照服务协议约定暂停或者不予拨付费用、追回违规费用、中止相关责任人员或者所在部门涉及医疗保障基金使用的医药服务，直至解除服务协议：定点医药机构及其相关责任人员有权进行陈述、申辩。医疗保障经办机构违反服务协议的，定点医药机构有权要requireittomakerectificationorrequestthehealthcaresecurityadministrativedepartmenttocoordinatethehandlingorurgetherectification,ormayapplyforadministrativereconsiderationorfileanadministrativelawsuitinaccordancewiththelaw.ArtiClC14Thedesignatedmedicalinstitutionshallestablishinternalmanagementrulesfortheuseofhealthcaresecurityfunds,designateaspecialbodyorpersonneltoberesponsiblefortheadministrationoftheuseofhealthcaresecurityfunds,andestablishandimprovetheexaminationandevaluationsystem.Thedesignatedmedicalinstitutionshallorganizetrainingontherulesandpoliciesonhealthcaresecurityfunds,inspectitsuseofhealthcaresecurityfundsonaperiodicalbasis,andcorrecttheirregularuseofhealthcaresecurityfundsinatimelymanner.Article15Adesignatedmedicalinstitutionanditsemployeesshallimplementthemanagementprovisionsonreal-namemedicaltreatmentanddrugpurchase,verifythehealthcaresecuritycertificateoftheinsured,providereasonableandnecessarymedicalservicesaccordingtodiagnosisandtreatmentrules,andtruthfullyissueexpensevouchersandrelevantmaterialstotheinsured,shallnotconductdecompositionofhospitalizationorcounterfeithospitalization,shallnotconductexcessivediagnosisandtreatmentandexcessivecheck,deliberatelyseparateone求纠正或者提请医疗保障行政部门协调处理、督促整改,也可以依法申请行政复议或者提起行政诉讼。第十四条定点医药机构应当建立医疗保障基金使用内部管理制度，由专门机构或者人员负责医疗保障基金使用管理工作，建立健全考核评价体系。定点医药机构应当组织开展医疗保障基金相关制度、政策的培训，定期检查本单位医疗保障基金使用情况，及时纠正医疗保障基金使用不规范的行为。第十五条定点医药机构及其工作人员应当执行实名就医和购药管理规定，核验参保人员医疗保障凭证，按照诊疗规范提供合理、必要的医药服务，向参保人员如实出具费用单据和相关资料，不得分解住院、挂床住院，不得违反诊疗规范过度诊疗、过度检查、分解处方、超量开药、重复开药，不得重复收费、超标准收费、分解项目收费，不得串换药品、医用耗材、诊疗项目和服务设施，不得诱导、协助他人冒名或者虚假就医、购药。prescriptionintomany,prescribemoredrugsthannecessary,orgivethesameprescriptionasothermedicalinstitutionstothesamepatientinviolationofdiagnosisandtreatmentrules,shallnotchargefeesrepeatedly,beyondtheprescribedrates,orconductdecompositionofcharges,shallnotexchangedrugs,medicalsupplies,diagnosisandtreatmentitemsandservicefacilities,andshallnotinduceorassistotherstoseekmedicaltreatmentorpurchasedrugsunderthenameofanotherpersonorinafalsemanner.Adesignatedmedicalinstitutionshallensurethatthepaymentofhealthcaresecurityfundsfallswiththespecifiedscopeofpayment.Exceptforemergencytreatment,rescueandotherspecialcircumstances,theconsentoftheinsuredorhisorhercloserelativeorguardianshallbeobtainedfortheprovisionofmedicalservicesbeyondthescopeofpaymentOfhealthcaresecurityfunds.Article16Adesignatedmedicalinstitutionshallpreservefinancialaccounts,accountingvouchers,prescriptions,medicalrecords,treatmentandcheckrecords,breakdownofexpenses,warehouseentryandexitrecordsofdrugsandmedicalsuppliesandothermaterialsasrequired,promptlytransmitthedataontheuseofhealthcaresecurityfundsthroughthehealthcaresecurityinformationsysteminacomprehensiveandaccuratemanner,reporttheinformationneededforthesupervisionandadministrationoftheuseOfhealthcaresecurityfundstothehealthcaresecurityadministrativedepartment,releasetothepublicmedicalexpenses,coststructureandotherinformation,andacceptsocialsupervision.定点医药机构应当确保医疗保障基金支付的费用符合规定 的支付范围；除急诊、抢救等特殊情形外，提供医疗保障 基金支付范围以外的医药服务的，应当经参保人员或者其 近亲属、监护人同意。第十六条定点医药机构应当按照规定保管财务账 目、会计凭证、处方、病历、治疗检查记录、费用明细、 药品和医用耗材出入库记录等资料，及时通过医疗保障信 息系统全面准确传送医疗保障基金使用有关数据，向医疗 保障行政部门报告医疗保障基金使用监督管理所需信息， 向社会公开医药费用、费用结构等信息，接受社会监督。第十七条参保人员应当持本人医疗保障凭证就Article 17 Theinsuredshallseekmedicaltreatmentandpurchasedrugsbasedonhisorherownhealthcaresecurityreturn of cash or in kind, or obtain other illegal benefits.利益。certificate,andvoluntarilypresentitforcheck.Theinsuredhastherighttorequirethedesignatedmedicalinstitutiontoissueexpensevouchersandrelevantmaterialsinatruthfulmanner.Theinsuredshallproperlykeephisorherownhealthcaresecuritycertificateandpreventothersfromusinghisorherhealthcaresecuritycertificate.Iftheinsuredneedstoentrustanotherpersonwiththepurchaseofdrugsonbehalfthereofforanyparticularreason,theidentificationoftheinsuredandtheentrustedpersonshallbeprovided.Theinsuredshallobtainhealthcaresecuritybenefitsaccordingtoapplicableprovisionsandshallnotobtainbenefitsrepeatedly.Theinsuredhastherighttorequirethehealthcaresecurityagencytoprovidehealthcaresecurityconsultingservicesandofferrecommendationsontheimprovementoftheuseofhealthcaresecurityfunds.Article 18 Thehealthcaresecurityoranyotheradministrativedepartment,thehealthcaresecurityagency,designatedmedicalinstitutionoranyofitsemployeesshallnotacceptbribesorobtainotherunlawfulincomeintheuseofhealthcaresecurityfunds.Article 19 Theinsuredshallnottakeadvantageoftheiraccesstohealthcaresecuritybenefitstoreselldrugs,acceptthe医、购药，并主动出示接受查验。参保人员有权要求定点医药机构如实出具费用单据和相关资料。参保人员应当妥善保管本人医疗保障凭证，防止他人冒名使用。因特殊原因需要委托他人代为购药的，应当提供委托人和受托人的身份证明。参保人员应当按照规定享受医疗保障待遇，不得重复享受。参保人员有权要求医疗保障经办机构提供医疗保障咨询服务，对医疗保障基金的使用提出改进建议。第十八条在医疗保障基金使用过程中，医疗保障等行政部门、医疗保障经办机构、定点医药机构及其工作人员不得收受贿赂或者取得其他非法收入。第十九条参保人员不得利用其享受医疗保障待遇的机会转卖药品，接受返还现金、实物或者获得其他非法Thedesignatedmedicalinstitutionshallnotprovideconveniencefortheinsuredtotakeadvantageoftheiraccesstohealthcaresecuritybenefitstoreselldrugs,acceptthereturnofcashorinkind,orobtainotherillegalbenefits.Article 20 Thehealthcaresecurityagency,designatedmedicalinstitutionoranyotherentityoranyofitsemployees,theinsuredoranyotherpersonshallnotfraudulentlyobtainhealthcaresecurityfundsbysuchmethodsasforging,altering,concealing,tamperingwithordestroyingmedicalinstruments,medicalcertificates,accountingvouchers,electronicinformationorotherrelevantmaterials,orbyfabricatingmedicalserviceitems.Article 21 Healthcaresecurityfundsshallbeusedfordesignatedpurposesonly,andshallnotbeembezzledormisappropriatedbyanyorganizationorindividual.ChapterIIISupervisionandAdministrationArticle22Healthcaresecurity,health,traditionalChinesemedicine,marketregulation,finance,audit,publicsecurityandotherdepartmentsshallcooperatewitheachotheraccordingtothedivisionofwork,establishmechanismsofcommunicationandcoordination,andcasetransfer,amongothers,andjointlyconductthesupen,isionandadministrationoftheuseofhealthcaresecurityfundsinaneffectivemanner.Healthcaresecurityadministrativedepartmentsshallstrengthenthesupervisionofmedicalservicesandmedical定点医药机构不得为参保人员利用其享受医疗保障待遇的机会转卖药品，接受返还现金、实物或者获得其他非法利益提供便利。第二十条医疗保障经办机构、定点医药机构等单位及其工作人员和参保人员等人员不得通过伪造、变造、隐匿、涂改、销毁医学文书、医学证明、会计凭证、电子信息等有关资料，或者虚构医药服务项目等方式，骗取医疗保障基金。第二十一条医疗保障基金专款专用，任何组织和个人不得侵占或者挪用。第三章监督管理第二十二条医疗保障、卫生健康、中医药、市