Procedures of Shanghai Municipality on the Pilot Program of Long-term Nursing Insurance

(December 30, 2017)

SMPG G [2017] No. 97

Article 1(Purposes and Basis)

With a view to strengthening the social security system, exploring the establishment of long-term nursing insurance system, safeguarding the basic nursing needs of the disabled, and actively responding to the aging of population in Shanghai Municipality, these Procedures are formulated in accordance with relevant provisions of the Guiding Opinions of the General Office of the Ministry of Human Resources and Social Security on the Pilot Program of Long-term Nursing Insurance System (MHRSS GO G [2016] No. 80) and the Regulations of Shanghai Municipality on the Protection of the Rights and Interests of the Aged People.

Article 2(Definition)

The long-term nursing insurance in these Procedures refers to a social security system that is funded by social mutual aid and provides the long-term disabled, who are eligible for certain level of medical care through assessment, with service or financial guarantee for their basic life nursing and medical care closely related to their basic life.

Article 3(Scope of Application)

Any person who meets one of the following conditions shall participate in the long-term nursing insurance:

1. a policy holder of the employees’ basic medical insurance (hereinafter referred to as the EBMI) of this Municipality (hereinafter referred to as a person in Category I); or

2. a policy holder, of or over 60 years old, of the basic medical insurance for urban and rural residents (hereinafter referred to as the BMIUR) of this Municipality (hereinafter referred to as a person in Category II).

Article 4(Departmental Responsibilities)

The Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office) is the competent department of the long-term nursing insurance of this Municipality, responsible for the policy formulation and unified administration of the long-term nursing insurance, as well as the supervision over the long-term nursing insurance fund. The Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office) shall, jointly with the Municipal Development & Reform Commission, the Municipal Civil Affairs Bureau, the Municipal Health and Family Planning Commission, and the Municipal Finance Bureau, promote the work on the unified needs assessment of the elderly nursing assessment. The district human resources and social security bureaus (the district medical insurance offices) shall be responsible for the administration over the long-term nursing insurance in their own districts.

The Municipal Development & Reform Commission shall be responsible for coordinating the policies over the pilot program of the long-term nursing insurance.

The Municipal Civil Affairs Bureau shall be responsible for the professional administration over the elderly nursing service institutions to operate the long-term nursing services, and coordinate in the arrangement of the elderly services resources. The Municipal Civil Affairs Bureau and the Municipal Health and Family Planning Commission shall jointly formulate the service norms for the long-term nursing insurance.

The Municipal Health and Family Planning Commission shall be responsible for the professional administration over the medical institutions to operate the long-term nursing services, strengthen the technical guidance on various nursing services covered by the long-term nursing insurance, promote the implementation of classified registration of the nursing beds and hospital beds in the medical institutions of this Municipality; and, jointly with the Municipal Civil Affairs Bureau, be responsible for the professional administration over the assessment institutions, and the implementation of the assessors’ training and the administration over the quality control of the assessments. The Municipal Health and Family Planning Commission and the Municipal Civil Affairs Bureau shall, jointly with the Municipal Human Resource and Social Security Bureau (the Municipal Medical Insurance Office) and other relevant departments, formulate and/or revise the standards for the unified needs assessment of the elderly nursing.

The Municipal Finance Bureau shall provide finance guarantee relevant to the long-term nursing insurance and supervise over the fund management as required by relevant provisions.

Each district people’s government shall actively support the work on the long-term nursing insurance in the organization and implementation, funding and human resources.

The Municipal Administration Center for Social Security and the Municipal Administration Center for Medical Insurance (hereinafter referred to as the Municipal Medical Insurance Center) shall be responsible for raising funds for the long-term nursing insurance.

The Municipal Medical Insurance Center and the administration center for medical insurance affairs in all districts (hereinafter referred to as the district medical insurance center) are operation agencies of the long-term nursing insurance. The Municipal Medical Insurance Center shall be responsible for the settlement of expenses, funding allocation, and establishment and maintenance of relevant information systems for the long-term nursing insurance. The district medical insurance center shall be responsible for the detailed daily business of the long-term nursing insurance in its own district.

Entrusted by the Municipal Human Resources and Social Security Bureau, the Municipal Supervision and Inspection Office of Medical Insurance shall implement the concrete supervision, inspection and administrative law enforcement over the long-term nursing insurance.

Article 5 (Registration and Premium Payment)

Persons in Category I and Category II may, respectively according to relevant provisions in the existing EBMI and BMIUR on registration and payment, complete the registration and pay the premium.

Article 6 (Funding)

The funding level for the long-term nursing insurance shall be reasonably determined according to the principle of the expenditure determined by the revenue, balance between the revenue and the expenditure with certain surplus, and may make a timely adjustment based on the social economic development of this Municipality and the actual operation of the fund.

The long-term nursing insurance fund for persons in Category I shall be raised by quarterly re-allocating the EMBI pooling funds based on 1% of the employer’s contribution base.

The long-term nursing insurance fund for persons in Category II shall be raised by quarterly re-allocating the BMIUR pooling funds based on the number of the insured of or over 60 years old, the contribution amount of which is a little lower than the average contribution of the persons in Category I. The specific fund-raising standards shall be made after a discussion among the Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office), the Municipal Finance Bureau, and other relevant departments, be reported to the Municipal People’s Government and implemented upon its approval.

Article 7(Fund Management)

The management of the long-term nursing insurance fund shall be implemented in the light of relevant national and municipal provisions on the administration over the social security funds. The long-term nursing insurance fund shall be incorporated into the special financial accounts of social security funds under a unified management and a policy of special fund for special use. The operation agencies shall establish separate accounts based on Category I and Category II. Where such accounts are insufficient and need a fiscal subsidy, it shall be reported to the Municipal People’s Government and be implemented upon the latter’s approval. The long-term nursing insurance fund shall, as required by relevant provisions, be subject to the supervision of the finance and auditing departments.

Article 8(Assessment)

The unified needs assessment for the nursing of the elderly and the service management shall be implemented according to relevant municipal provisions.

Any eligible assessment institution may apply to, and sign a service contract with the Municipal Medical Insurance Center as a designated assessment institution of the long-term nursing insurance (hereinafter referred to as a designated assessment institution).

Persons in Category I of or over 60 years old who have completed the procedures for receiving basic pension, and persons in Category II shall, according to relevant municipal provisions on the unified needs assessment of the nursing of the elderly, apply for a unified needs assessment. The designated assessment institution shall determine different assessment grading of the unified needs for elderly nursing after a comprehensive assessment on their self-care ability and disease status (hereinafter referred to as assessment grading).

The long-term nursing insurance fund shall cover 80% of the standardized assessment fees that are incurred due to a policy holder’s application for such insurance benefits. The payment for a review and a final review on the assessment shall be separately formulated by the Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office).

Article 9(Designated Nursing Service Institutions)

The elderly nursing institutions, community elderly nursing service institutions and medical institutions (e.g., a nursing station) that are legal persons established in accordance with law and are able to provide long-term nursing service may apply to and sign a service contract with the Municipal Medical Insurance Center after an assessment as the designated nursing service institutions of the long-term nursing insurance (hereinafter referred to as designated nursing service institutions).

During the pilot program period, the designated medical institutions for recipients of basic medical insurance in this Municipality that provide elderly nursing services may be regarded as designated nursing service institutions.

The designated nursing service institutions shall sign labor contracts or reach agreements with the nursing staff.

Article 10(Nursing Staff)

Persons who provide long-term nursing insurance services shall be nurse practitioners or those who have participated in vocational training such as the elderly nursing, medical care, and health care and have obtained corresponding qualifications, as well as other qualified persons.

Article 11(Service Modes)

1. Home nursing in community. The elderly nursing service institutions, and grassroots medical and health institutions and nursing homes such as nursing stations, outpatient departments and community health service centers provide basic life nursing and medical care and nursing service closely related to the basic daily life for policy holders who stay at home by visits or community care and nursing.

2. Nursing in the elderly nursing institutions. The elderly nursing institutions provide basic life nursing and medical care and nursing service closely related to the basic daily life for policy holders who live in the institutions.

3. Hospital care and nursing. The grassroots medical and health institutions, including the community health service centers, nursing homes, and some medical institutions of secondary class or above which also offer elderly nursing service provide medical care and nursing services for policy holders who take the nursing beds in the institution.

Article 12(Contents of Service)

The service contents and norms for home nursing in community and in the elderly nursing institutions covered by the long-term nursing insurance shall be separately formulated by the Municipal Civil Affairs Bureau, the Municipal Human Resources and Social Security Bureau and the Municipal Health and Family Planning Commission.

The hospital care and nursing service shall be provided with reference to the therapy, facilities and medication of EBMI.

Article 13(Conditions for Insurance Benefits)

In the pilot program period, the policy holders of or over 60 years old whose disability degree has reached between Grading 2 and Grading 6 after a disability assessment and the assessment which is still valid, may be entitled to the long-term nursing insurance benefits. As required by relevant provisions, the persons in Category I shall have also completed the procedures for receiving basic pension.

The long-term nursing insurance policy period for persons either in Category I or in Category II shall be set the same as the periods of EBMI and BMIUR respectively.

Article 14(Benefits for Home Nursing in Community)

1. The policy holders whose assessment grading is between Grading 2 and Grading 6 may be entitled to home nursing in community. During the pilot program period, the home nursing service shall be provided in the following duration and frequencies:

3 times a week for those assessed as Grading 2 or Grading 3;

5 times a week for those assessed as Grading 4;

7 times a week for those assessed as Grading 5 or Grading 6; and

Each nursing service lasts for one hour.

2. To embody the principle of encouraging the elderly nursing at home, the policy holders who are assessed as Grading 5 or Grading 6 and take home nursing service may, if they have incessantly taken 1 to 6 months (including the 6th month) of home nursing service, have one additional service hour or 40 yuan as cash subsidy every month for their choice; those who have incessantly taken home nursing service for over 6 months may have two additional service hours or 80 yuan as cash subsidy every month for their choice.

3. The Municipal Medical Insurance Center shall agree on the prices of home nursing service in community and the long-term nursing insurance payment standard through the service contracts entered with the designated nursing service institutions.

4. The long-term nursing insurance fund covers 90% of the home nursing service charges incurred by the policy holders during a valid assessment period.

Article 15(Institutional Nursing Benefits)

1. The policy holders who are assessed as Grading 2 to Grading 6 may be entitled to institutional nursing service. The entry to the elderly nursing service institutions to ensure basic nursing services shall be subject to relevant provisions.

2. The Municipal Medical Insurance Center shall agree on the payment standard by the long-term nursing insurance for institutional nursing service through the service contracts entered with the designated nursing service institutions.

3. The long-term nursing insurance fund covers 85% of the standardized institutional nursing service charges incurred by the policy holders during a valid assessment period.

Article 16(Hospital Medical Care and Nursing Benefits)

The charges incurred by the policy holders in receiving hospital medical care and nursing service that are in compliance with provisions shall be subject to relevant regulations of EBMI or BMIUR that they participate in respectively.

The service charge standard for hospital care and nursing service shall be subject to relevant regulations on the existing compilations of medical service items and charges of the medical institutions in this Municipality.

In the pilot program period, the unified needs assessment for elderly nursing shall be gradually promoted. After passing such assessment, the recipients shall be entitled to hospital medical care and nursing service.

Article 17(Benefits Adjustment)

The Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office) may, based on such factors as the supplying capabilities of the long-term nursing service and the funding balance, adjust the benefits of home nursing in community and institutional nursing in collaboration with relevant departments, and report the adjustments to the Municipal People’s Government and implement them upon the latter’s approval and issuance.

Article 18(Excluded Scope of Payment)

The long-term nursing insurance fund shall not cover the following nursing service charges:

1. the service charges that shall be paid by the employment injury insurance fund;

2. the service charges that shall be borne by a third party;

3. the service charges that shall be borne by the public health; and

4. the service charges that are incurred abroad.

Article 19(Accounting and Payment)

The service charges that are incurred in the designated nursing service institutions to the policy holders and are covered by the long-term nursing insurance fund shall be kept first in the accounts of the designated institutions, and then be paid by the long-term nursing insurance fund according to relevant regulations; the rest shall be borne by the policy holders.

The service charges incurred by the services provided by the designated nursing service institutions to the policy holders that are outside the coverage of the long-term nursing insurance shall be paid by the policy holders.

Article 20(Settlements)

The hospitalization expenses incurred by the policy holders in the grassroots medical and health institutions (except for a few hospital beds), such as community health service centers, nursing homes, and secondary and above medical institutions that provide elderly nursing services, which are within the coverage of the long-term nursing insurance, shall be covered by the long-term nursing insurance fund; the hospitalization expenses incurred by the policy holders who spend over 90 accumulative hospitalization days in primary or above designated medical institutions within one year but do not have surgeries or other special treatments, shall be paid by the long-term nursing insurance fund where such charges are within the coverage of the long-term nursing insurance.

The above service charges, deducting the part which shall be borne by the policy holders, shall be first paid by the basic medical insurance fund. And at the end of the year, the long-term nursing insurance fund shall be settled with the EBMI and BMIUR funds respectively. The settlement scheme shall be formulated by the Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office) in negotiation with relevant departments, and the said Bureau (Office) shall report it to the Municipal People’s Government and implement it upon the latter’s approval.

Article 21(Management of Long-Term Nursing Insurance Service)

1. The policy holders shall show their social security cards as qualification documents for long-term nursing insurance services when they submit applications, accept assessments, take nursing services and make settlements. The operation agencies, designated assessment institutions and designated nursing service institutions shall verify their social security cards. No one shall fraudulently use, forge, alter or lend his/her own social security card.

2. The designated nursing service institutions shall consolidate the management requirements in accordance with the service contracts. Before providing home nursing in community and institutional nursing for the policy holders, they shall make service plans based on the assessment report, the time for payment as required and the actual circumstances of the policy holders, and then arrange their nursing staff to implement the plans accordingly.

3. The Municipal Medical Insurance Center shall reinforce routine management on the designated nursing service institutions in accordance with the service contract. The Municipal Supervision and Inspection Office of Medical Insurance shall exercise routine and special supervision and inspection over the long-term nursing insurance service, and supervise the service process of the designated assessment institutions and designated nursing service institutions.

Article 22(Information Management)

An information system for long-term nursing insurance shall be established to realize the inter-connection with the designated assessment institutions and designated nursing service institutions to digitalize the assessment, acceptance, service and settlement of the long-term nursing insurance. A sub-system for home nursing in community based on the mobile network and smart terminals to realize the delivery of service, monitoring of service time, assessment of service results and risk warning calls in the process of the door-to-door service shall be established to realize an interconnection and share of information with the professional management departments.

The designated nursing service institutions shall upload the factual service, time and charges for the services to the long-term nursing insurance information system.

Article 23(Risk Prevention and Control)

The designated nursing service institutions shall buy third-party liability insurance. The commercial insurance companies shall provide relevant coverage as required by the market rules to indemnify the compensation against any contingency or accident arising from the servicing of the designated nursing service institutions and their staff.

The designated nursing service institutions shall strengthen internal management and promote risk awareness and the capabilities in responding to emergencies.

Article 24 (Responsibilities)

1.The Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office) shall order corrections against any designated assessment institutions and designated nursing service institutions and recover the service charges where there are any acts that violate laws or regulations in the process of conducting assessment on long-term nursing insurance needs or providing nursing services that have caused losses to the long-term nursing insurance fund; in serious cases, their business related to the long-term nursing insurance shall be suspended until relevant service contracts are terminated; if their acts constitute crimes, they shall be subject to criminal liability by law.

2. The Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office) shall recover the relevant expenses from the policy holders or other persons who have committed insurance fraud and/or other acts violating laws or regulations that have caused losses to the long-term nursing insurance fund in the process of accepting needs assessments and/or enjoying long-term nursing insurance services; if their acts constitute crimes, they shall be subject to criminal liability by law.

3. The Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office) shall order corrections against any one of the following acts committed by the operation agencies and their staff; if their acts have caused any losses against the long-term nursing insurance fund, or an employer or individual, the liability of compensation shall be ordered; and the person in direct charge and other related people shall be punished by law:

1. fail to perform legal obligations to the long-term nursing insurance;

2. fail to deposit the long-term nursing insurance fund into the special financial accounts;

3. withhold or refuse to pay the long-term nursing insurance benefits in time;

4. lose or falsify the payment records, long-term nursing insurance benefits records and other data and the policy holder’s benefits records; or

5. any other acts that violate laws or regulations.

Article 25(Miscellaneous)

In the pilot program period, the special financial accounts of EBMI and BMIUR funds will be separately re-allocated to the special financial account of the long-term nursing insurance fund according to the provisions of these Procedures. A sub-account shall be opened under the Municipal Medical Insurance Center’s account of special funds for medical security to pay the charges incurred during the pilot program period that are in compliance with regulations on the long-term nursing service insurance.

The policies connecting the long-term nursing insurance and the elderly nursing subsidy shall be separately formulated by the Municipal Civil Affairs Bureau and the Municipal Finance Bureau jointly with other relevant departments.

The third-party commercial insurance companies may provide commercial insurance products related to the long-term nursing service by making use of the result of the unified needs assessments of the elderly nursing. The policy holders of the long-term nursing insurance are encouraged to buy commercial long-term nursing insurance as a supplement. The role of various social organizations including the qualified commercial insurance companies shall be fully played to improve the capabilities of operation management and servicing.

These Procedures shall be effective as of January 1, 2018 and be valid until December 31, 2019. The Pilot Procedures of Shanghai Municipality for Long-term Nursing Insurance (SMPG G [2016] No. 110) printed and distributed by the Municipal People’s Government in December 2016, and the Opinions on Carrying Out the Pilot Program of Medical Care and Nursing Plan for the Senior Old Aged (SMPG GO [2016] No. 67) formulated by eight municipal departments including the Municipal Human Resources and Social Security Bureau, and transmitted by the General Office of the Municipal People’s Government in August 2016 shall be simultaneously repealed.