Regulations of Shanghai Municipality on Healthcare Security

(Adopted at the 18th Session of the Standing Committee of the 16th Shanghai Municipal People's Congress on December 31, 2024)

Chapter I General Provisions

Article 1

With a view to regulating relationship in healthcare security, improving the multi-level healthcare security system, optimizing healthcare security services, safeguarding citizens' legitimate rights and interests in healthcare security, promoting the high-quality development of the healthcare security cause, and ultimately advancing the development of Healthy Shanghai initiatives, these Regulations are formulated in accordance with the Social Insurance Law of the People's Republic of China, the Law of the People's Republic of China on Basic Healthcare and Health Promotion, the Regulations on the Supervision and Administration of Use of the Healthcare Security Fund, and other laws and administrative rules, and in the light of the actual circumstances of this Municipality.

Article 2

These Regulations. shall apply to the establishment, operation, and management of the healthcare security system, including fund administration, pharmaceutical and healthcare oversight, service delivery, and regulatory supervision within the administrative areas of this Municipality.

Article 3

The healthcare security cause in this Municipality shall center on the people's health, with the aim to establish a sustainable multi-level healthcare security system that covers the entire population, integrates the urban and rural healthcare security systems, defines rights and responsibilities, and provides appropriate security. The level of healthcare security shall be commensurate to the level of economic and social development. Efforts shall be made to promote the coordinated development and governance of medical care, healthcare security, and pharmaceuticals, with a view to ensuring that the people have access to high-quality, efficient, and affordable medical services.

Article 4

The municipal and district people's governments shall strengthen leadership over the healthcare security work, incorporate the healthcare security cause into the national economic and social development plans, include the work on healthcare security in government performance evaluations, and coordinate major issues related to healthcare security.

The town/township people's governments and the sub-district offices shall, within their respective jurisdictions, ensure the effective implementation of healthcare security-related tasks and guide neighborhood committees and villagers' committees in assisting with the collection of information on basic medical insurance enrollment and medical assistance, as well as the dissemination of relevant policies.

Article 5

The healthcare security departments shall be responsible for the healthcare security administration within their respective administrative areas. Their affiliated healthcare security administration agencies shall fulfill relevant administration and service functions in respect to healthcare security in accordance with the provisions.

The departments of health, medical products administration, finance, tax service, civil affairs, human resources and social security, development and reform, education, finance regulation, market regulation, science and technology, economy and informatization, and data, as well as the entities of medical institution organizer entrusted by the Municipal People’s Government shall perform their respective duties in the relevant healthcare security work.

Article 6

Citizens have the right and obligation to participate in the basic medical insurance in accordance with law. Employers shall ensure that their employees participate in the basic medical insurance for employees.

This Municipality shall guide citizens to raise awareness to actively participate in the insurance, and achieve full coverage of the basic medical insurance, through such measures as strengthening the publicity and interpretation of healthcare security laws, rules, regulations, and policies, and improving the services for and enhancing the convenience of medical insurance participation.

Article 7

Mass organizations such as trade unions, disabled persons' federations, and the Red Cross Society shall leverage their advantages and collaborate to do well the relevant work of healthcare security in accordance with their respective functions and duties, or charters.

Article 8

Pharmaceutical and other related industry associations shall formulate and implement their self-regulatory norms in accordance with law, provide information, training and other relevant services for their members, and guide and supervise medical institutions and pharmaceutical businesses to operate in good faith and to make reasonable use of healthcare security funds in accordance with law. Pharmaceutical-related professional organizations and industry experts are encouraged to play a decision-making advisory and technical support role, and to assist in raising the level of professionalism in healthcare security governance.

Article 9

This Municipality shall promote the digital transformation of the healthcare security cause, strengthen the development and utilization of healthcare security data resources, and empower the administration and services of healthcare security and related fields.

This Municipality shall promote the open utilization and authorized operation of the healthcare security data in accordance with law, unlocking the value of data elements, and supporting the high-quality development of the healthcare security cause.

Article 10

This Municipality shall strengthen cross-regional healthcare security and service collaboration in accordance with national provisions, promote coordinated supervision over the healthcare security funds, facilitate in the Yangtze River Delta region the sharing of healthcare security public services and the mutual recognition of cross-regional medical supervision standards, as well as the enjoyment of cross-regional long-term care insurance services and fee settlement thereof, and implement direct settlement without prior registration for cross-regional medical services in the demonstration zone of green and integrated ecological development of the Yangtze River Delta.

Chapter II Healthcare Security System

Article 11

This Municipality shall establish a multi-level healthcare security system with the basic medical insurance as the principal part, medical assistance as the bottom line, and the joint development of the supplementary medical insurance, medical mutual aid, commercial health insurance, and charitable assistance.

Article 12

The basic medical insurance in this Municipality includes the basic medical insurance for employees and the basic medical insurance for urban and rural residents.

Employees shall participate in the basic medical insurance for employees. Self-employed individuals without employees, part-time workers not covered by the basic medical insurance for employees in their employer entities, and other workers with flexible employment (hereinafter jointly referred to as the "flexible workers") are eligible to participate in the basic medical insurance for employees. Those not participating in the basic medical insurance for employees may participate in the basic medical insurance for urban and rural residents in accordance with the provisions.

A basic-medical-insured individual shall not participate in two or more basic medical insurance programs or enjoy the benefits of two or more basic medical insurance programs during the same time period.

Article 13

The premiums of the basic medical insurance for employee shall be paid jointly by employers and employees, and the part of premiums that shall be paid by the employees shall be withheld and remitted by the employers. Flexible workers participating in the basic medical insurance for employees shall pay their premiums in accordance with the provisions.

The contribution base for the basic medical insurance for employees shall align with the social insurance contribution base of this Municipality. The contribution rate shall be jointly established by the municipal healthcare security department and the municipal finance department, subject to approval by the Municipal People's Government prior to implementation.

Article 14

The contributions to the basic medical insurance for urban and rural residents shall consist of both individual payments and fiscal subsidies, be linked to the economic and social development level and residents' per capita disposable income, and maintain a reasonable ratio between fiscal subsidies and individual payments. The standards of individual payments and fiscal subsidies shall be determined based on the age categories of insured individuals.

This Municipality shall provide subsidies to cover the individual contribution portion of the basic medical insurance for urban and rural residents for eligible medical assistance beneficiaries, severely disabled persons, elderly individuals, and the elder dependents of deceased employees. People with multiple eligible statuses mentioned above shall be granted subsidies of the highest standard that may be enjoyed among all their statuses.

Article 15

Where an employer and its employees have paid the basic medical insurance premiums in accordance with the provisions, the employees shall be entitled to the basic medical insurance benefits. If an employer or its employees have not paid the premiums in accordance with the provisions, the employees shall not be entitled to such benefits. If the employer and its employees subsequently make up the unpaid premiums in accordance with the provisions, the employees may resume their entitlement to the basic medical insurance benefits. Medical expenses incurred during the suspension of benefits shall not be covered by the basic medical insurance fund.

Flexible workers who participate in the basic medical insurance for employees shall be entitled to the corresponding benefits after the waiting period for the benefits has expired.

Unemployed individuals who participate in the basic medical insurance for employees during the period of receiving unemployment insurance benefits may enjoy the basic medical insurance benefits. The premiums payable by unemployed individuals shall be covered by the unemployment insurance fund, and no individual payment shall be required.

Article 16

Participants in the basic medical insurance for employees who have reached the statutory retirement age, and whose accumulated contribution years and contribution years in this Municipality have reached the required number of years when they go through the retirement procedures shall be entitled to the basic medical insurance benefits for retirees. Those who have not met the required number of years may continue to pay contributions until the requirement is fulfilled, after which they shall be entitled to the basic medical insurance benefits for retirees.

Article 17

Individuals who pay the basic medical insurance premiums during the centralized enrollment period for the basic medical insurance for urban and rural residents and maintain continuous participation shall be entitled to the benefits from the following year. Those who enroll outside the centralized enrollment period or fail to maintain the continuous participation shall be entitled to the benefits upon the completion of the waiting period. Where the State or this Municipality has separate provisions on the enrollment, premium payment, and entitlement to benefits for special groups such as newborns under the basic medical insurance for urban and rural residents, such provisions shall prevail.

Article 18

This Municipality shall establish and improve supplementary medical insurance systems, including critical illness insurance for urban and rural residents, and high-cost medical expense subsidies for employees.

Individuals enrolled in the basic medical insurance for urban and rural residents or that for employees may apply to enjoy critical illness insurance for urban and rural residents or high-cost medical expense subsidies for employees in accordance with the provisions.

Article 19

This Municipality shall improve the medical assistance system, and implement categorized assistance based on the classification of assistance recipients. The scope of medical assistance recipients includes:

1. extremely impoverished individuals;

2. family members of households receiving minimum living allowances;

3. family members of households on the edge of minimum living allowances;

4. family members of households facing difficulties due to rigid expenditure; 

5. and other individuals identified by the State or this Municipality as experiencing special hardships, such as orphans who do not live in welfare houses, children in distress who are recipients of basic living allowances, and recipients of regular fixed subsidies from civil affairs authorities.

Article 20

For extremely impoverished individuals, family members of households receiving minimum living allowances, elderly individuals aged 60 or above from households on the edge of minimum living allowances, and other medical assistance recipients determined in accordance with relevant provisions, who participate in the basic medical insurance for urban and rural residents of this Municipality, partial or full subsidies shall be provided for their personal contributions.

After medical assistance recipients have received coverage through basic medical insurance and supplementary medical insurance, subsidies shall be provided for their eligible out-of-pocket expenses. However, in accordance with the provisions, the relevant out-of-pocket expenses on the part of the aforementioned insured individual who is punished by the healthcare security department for his/her violation of law shall not be calculated as the eligible out-of-pocket expenses for receiving subsidies for supplementary medical insurance and for medical assistance.

The medical assistance standards shall be determined based on the degree of financial hardship of the recipient's family, the social economic development level, the public health needs, and the financial capacity of the medical assistance fund.

Article 21

This Municipality shall improve the maternity insurance system, implement measures to support childbirth, and refine the pricing and items of assisted reproductive medical services as well as the management of basic medical insurance payments therefor in accordance with the provisions.

Maternity insurance benefits include maternity allowances and maternity medical expenses. Maternity medical expenses consist of subsidies for maternity medical costs, and hospitalization expenses during childbirth settled and paid in accordance with the provisions on the basic medical insurance for employees. The duration of maternity allowance payments shall comply with the legally prescribed periods of maternity leave and childbirth leave.

Maternity insurance is implemented in conjunction with the basic medical insurance for employees in accordance with the provisions of the State and this Municipality.

Article 22

This Municipality shall implement a long-term care insurance system, and establish a stable funding mechanism to provide services or financial support for the basic nursing care needs of individuals with long-term disabilities, in accordance with the provisions of the State and this Municipality.

When insured individuals apply for an assessment under the long-term care insurance scheme designated assessment institutions shall assess the degree of their disability, medical condition and care needs in accordance with the assessment standards, and determine an assessment grade that accurately reflects their actual circumstances. The municipal assessment standards shall be formulated by the relevant departments including the municipal departments of health, civil affairs, and healthcare security in accordance with the national provisions.

Designated nursing institutions shall develop service plans for insured individuals based on their assessed level of care and the required service items, verify the identity of the insured individuals in accordance with the provisions, and provide nursing services and settle costs according to the relevant service items, standard specifications, duration and frequency. It is strictly prohibited to engage in fraudulent activities related to the settlement of long-term care insurance by means of forging, altering, or fabricating nursing records, medical history documents, financial accounts, electronic information, or by providing fictitious services.

Insured individuals shall not provide false information or materials when applying for or undergoing long-term care insurance assessments or receiving nursing services.

Article 23

This Municipality supports mass organizations such as trade unions and the Red Cross Society in organizing medical mutual aid for employees and hospitalization-related medical mutual aid initiatives for primary and secondary school students and infants. Participation in such medical mutual aid is voluntary and aims to alleviate the financial burden of medical expense for participants.

This Municipality encourages and guides social forces to provide charitable assistance through donations and other means.

Article 24

This Municipality encourages the development of commercial health insurance to fully leverage its supplementary protection function. Expenditures incurred by individuals purchasing eligible commercial health insurance products, or by employers purchasing the said products for their employees in a unified manner, may enjoy preferential policies in accordance with the national provisions.

This Municipality encourages and guides commercial insurance companies to develop commercial health insurance products that dovetail with the basic medical insurance and are accessible to all basic medical insurance participants. Individuals enrolled in the basic medical insurance for employees may use their personal medical insurance account balance from previous years to purchase eligible commercial health insurance products for themselves or their immediate family members.

Chapter III Healthcare Security Funds

Article 25

The healthcare security funds of this Municipality include the basic medical insurance fund and the medical assistance fund.

The healthcare security funds shall implement the unified national accounting system, financial system, and fund budgeting and final accounts system, and shall be deposited into fiscal special accounts and used exclusively for designated purposes.

The use of the healthcare security funds shall conform to the payment scope, items and standards prescribed by the State and this Municipality. No organization or individual shall misappropriate or embezzle such funds.

Article 26

The tax authorities are responsible for collecting the basic medical insurance premiums for employees and those for urban and rural residents in accordance with the provisions shall promptly notify the healthcare security department of the collection information.

Article 27

The budget management of the basic medical insurance fund shall adhere to the principles of "determining expenditure based on revenue, balancing revenue and expenditure, ensuring slight surpluses" to maintain stable and sustainable operation of the fund.

The municipal healthcare security administration agency shall be responsible for preparing the draft budget for the next year’s basic medical insurance fund and submit it to the municipal healthcare security department for review. The revenue budget for the basic medical insurance fund shall be prepared by the municipal healthcare security administration agency jointly with the municipal tax authorities.

The basic medical insurance fund shall achieve balance between revenue and expenditure through budgeting. The municipal departments of healthcare security and finance shall strengthen supervision over the budget execution of the basic medical insurance fund and conduct performance evaluation thereof.

Article 28

This Municipality shall establish a risk early warning and control mechanism for the operation of the basic medical insurance fund. If an operational risk thereof arises, adjustments to the fundraising standard or to the benefit policy shall be implemented to ensure balance between the revenue and expenditure of the fund. In cases of payment shortfalls, subsidies shall be provided therefor.

Article 29

The basic medical insurance fund covers expenses for medicines, medical consumables and medical service items as specified in the relevant catalogs.

The following medical expenses are not covered by the basic medical insurance fund:

1. expenses payable by the work-related injury insurance fund;

2. expenses that shall be borne by a third party;

3. expenses that shall be borne by the public health programs;

4. expenses incurred by medical services overseas; 

5. and other expenses excluded from such payment as prescribed by the State.

If the basic medical insurance fund covers medical expenses that shall be borne by a third party, the healthcare security administration agency has the right to seek the reimbursement in accordance with law.

Article 30

The medical assistance fund shall be financed through multiple channels, including general public budget revenue, welfare lottery public-welfare revenue, and social donations. It shall be managed and used under the principles of ensuring funds being used exclusively for designated purposes and balancing revenues and expenditures.

Chapter IV Healthcare Security and Pharmaceutical Administration

Article 31

In accordance with the provisions of the State, this Municipality implements designated medical institutions and retail pharmacies (hereinafter jointly referred to as the "medical and pharmaceutical institutions") management for healthcare security. The municipal healthcare security administration agency shall enter into healthcare security service agreements (hereinafter referred to as the "service agreements") with qualified medical and pharmaceutical institutions, determining them as designated medical and pharmaceutical institutions. The list of designated medical and pharmaceutical institutions shall be promptly made public.

Where a designated medical institution approved to provide internet medical services needs to settle online medical expenses covered by the basic medical insurance fund, it shall enter into a supplementary agreement with the municipal healthcare security administration agency.

Designated medical and pharmaceutical institutions shall provide medical and pharmaceutical services in accordance with the service agreements, and the municipal healthcare security administration agency shall promptly settle and disburse expenses covered by the basic medical insurance fund.

Article 32

Designated medical and pharmaceutical institutions shall establish their internal healthcare security management systems in accordance with the national provisions and the service agreements, organize training on the policies related to the healthcare security fund, regularly inspect the use of the healthcare security fund within their respective units, and promptly correct any illegal or non-compliant act.

Designated medical and pharmaceutical institutions' settlement of expenses covered by the basic medical insurance shall correspond to the medical and pharmaceutical services actually provided, ensuring that the quantities of medicines and medical consumables procured and used match the healthcare security fund settlement accounts. Expenses that shall be covered by the healthcare security fund shall not be imposed on the insured individuals.

The healthcare security departments and healthcare security administration agencies shall strengthen guidance and training for the internal healthcare security management departments or dedicated (part-time) healthcare security management personnel of the designated medical and pharmaceutical institutions.

In accordance with the national provisions, this Municipality shall enhance the construction of platforms such as medical institution examination and test result databases. The designated medical institutions shall implement information sharing and mutual recognition of medical examination and test results according to the provisions.

Article 33

The municipal healthcare security department shall improve the functions of the centralized pharmaceutical procurement platform of this Municipality (hereinafter referred to as the "centralized procurement platform") and guide the centralized pharmaceutical procurement institutions in this Municipality in managing the bidding, procurement, transactions, and settlements.

Enterprises supplying medicines and medical consumables on the centralized procurement platform shall truthfully declare through the platform such information as the prices and supply capacities of the medicines and medical consumables. Any change in the relevant information shall be promptly declared for an adjustment.

The designated medical institutions shall procure medicines and medical consumables in accordance with the service agreements.

Article 34

The centralized volume-based procurement of medicines and medical consumables in this Municipality shall adhere to the principles of demand orientation, quality priority, integration of bidding and procurement, and linkage between volume and price, so as to protect fair market competition.

Medical institutions participating in the centralized volume-based procurement shall reasonably fill in the volume of procurement demand based on their actual clinical needs and fulfill the agreed procurement volumes, settling the payments promptly and accurately. Designated retail pharmacies are encouraged to participate in the centralized volume-based procurement. Enterprises selected in the centralized volume-based procurement shall ensure the quality of the selected products, and supply sufficient products in a timely manner.

This Municipality shall establish mechanisms for monitoring and evaluating the supply capacity and product quality of selected enterprises in the centralized volume-based procurement. The municipal healthcare security department shall regularly monitor the changes in the supply of selected products. The medical products administrative department shall strengthen quality supervision over the selected products in the centralized volume-based procurement, continuously track and monitor the adverse reactions to such products, and provide regular feedback to the healthcare security department. Where a medical or pharmaceutical institution finds a selected product from the centralized volume-based procurement is suspected of relevant quality issues or adverse reactions, it shall promptly report to the medical products administrative department.

Article 35

The municipal healthcare security department shall monitor the price information of medicines and medical consumables, analyze and evaluate the abnormal price fluctuations thereof, and collaborate with the municipal competent departments for price control and market regulation to maintain the pricing order of medicines and medical consumables.

Medical institutions shall disclose information regarding the prices of medicines and medical consumables.

Article 36

Government-guided pricing management shall be implemented for the basic medical service items provided by public medical institutions. Market-adjusted pricing shall apply to premium medical services, and newly added medical service items during their trial periods, and shall be reported by the relevant public medical institutions to the municipal healthcare security department in accordance with the provisions.

Market-adjusted pricing shall be implemented for the medical service items provided by non-public medical institutions. The pricing of medical service items of non-public designated medical institutions shall be managed in accordance with the service agreements.

Medical institutions shall publicly display the pricing information of their medical service items.

Article 37

This Municipality shall implement a multi-composite medical insurance payment method under the total budget management of the basic medical insurance fund for designated medical institutions. The health and healthcare security departments shall strengthen guidance and urge designated medical institutions to establish mechanisms for medical quality and medical cost control.

The health and healthcare security departments shall monitor the medical expenses of public medical institutions to ensure that the medical expense level matches the operation of the basic medical insurance fund and the affordability of the public.

Article 38

The municipal healthcare security department shall recommend eligible innovative medicines for inclusion in the national list of medical products payable by the healthcare security fund. For eligible innovative medical consumables, timely research shall be conducted to include them in the payment scope of the healthcare security fund in accordance with the procedures.

This Municipality shall take measures to increase support of healthcare security fund payment for innovative medicines, medical devices, and innovative medical service items.

Article 39

The municipal healthcare security department shall optimize the online transaction procedures of innovative medicines and medical consumables on the centralized procurement platform.

The designated medical institutions shall promptly equip and use corresponding innovative medicines and medical devices based on their clinical needs after the updates to and publicity of the national list of medicines payable by the healthcare security fund and list of new and superior biomedical products and medical devices.

Article 40

Under the premise of maintaining data security and protecting personal information and trade secrets, this Municipality shall establish a data cooperation and utilization mechanism among medical institutions, healthcare security departments, commercial insurance companies, and pharmaceutical enterprises through platforms such as the healthcare security big data innovation laboratory, and strengthen the application of data in scenarios such as innovative medicine research and development, clinical diagnosis and treatment, and commercial health insurance product development.

This Municipality supports the inclusion of highly innovative, definitely effective, and clinically urgently-needed innovative medicines and medical devices in the payment scope of commercial health insurance.

Article 41

This Municipality supports the opening of the medical service market to increase the supply of international and high-quality medical services, and supports eligible medical institutions in introducing overseas innovative medicines and medical devices.

Article 42

This Municipality shall strengthen the planning of medical resource allocation, improve the medical service system, promote the implementation of a hierarchical diagnosis and treatment system for basic medical services, and enhance the service capabilities of primary healthcare institutions.

This Municipality shall implement differentiated healthcare security fund payment policies for medical institutions of different levels, with appropriate priority support for primary healthcare institutions, to guide patients in hierarchical diagnosis and orderly diagnosis referrals.

Primary healthcare institutions shall, through family doctor contract services, provide basic medical and health management services for the insured individuals.

Article 43

The municipal healthcare security department shall reasonably determine the charging items and price standards for medical service items of traditional Chinese medicine (TCM), reflecting their clinical value and technical labor value, and implement dynamic adjustments thereto. In accordance with the provisions of the State and this Municipality, eligible TCM decoction pieces, TCM preparations of medical institutions, and TCM medical services with treatment effect and cost advantages shall be included in the payment scope of the basic healthcare security fund. Payment methods in line with TCM characteristics, such as payment based on the value of treatment effect for diseases where TCM has an advantage of treatment, shall be explored.

Article 44

Medical institutions are encouraged to provide diagnosis and treatment services for rare diseases based on their capabilities of diagnosis and treatment. The municipal healthcare security department shall ensure the payment for medicines used for rare diseases listed in the national list of medicines payable by the healthcare security fund.

Social forces are encouraged to participate in the diagnosis, treatment, research, and medicine supply of rare diseases to meet the patients' needs of medical and pharmaceutical services.

Chapter V Healthcare Security Agency Services

Article 45

This Municipality shall improve its healthcare security agency service system to achieve full coverage of healthcare security services at the municipal, district, town/township (sub-district), and village (community) levels. The municipal healthcare security department shall formulate a list of healthcare security agency service items and service guidelines and make them publicly available.

The healthcare security administration agencies shall strengthen standardization and regulation to provide accessible and convenient healthcare security agency services. Social insurance service agencies shall provide services such as medical insurance participation registration for employers, and achieve information sharing with the healthcare security administration agencies.

The municipal healthcare security department may entrust commercial insurance companies and mass organizations to handle relevant healthcare security agency services. The entrusted units shall share relevant handling data with the healthcare security administration agencies.

This Municipality shall promote new healthcare security agency service methods, achieving online and offline integration of service items through "Government Online-Offline Shanghai".

Article 46

The insured individuals shall proactively present their social security cards or medical insurance electronic vouchers and subject them to inspection when settling healthcare security payments for medical services and medicine purchase at designated medical and pharmaceutical institutions. The portion of expenses incurred at designated medical and pharmaceutical institutions in this Municipality that should be paid by the basic medical insurance fund shall be directly settled by the healthcare security administration agency and the designated medical and pharmaceutical institutions. In special circumstances as prescribed by this Municipality, the insured individual may apply to the healthcare security administration agency for miscellaneous reimbursement.

Where an insured individual seeks medical services at a designated medical institution in other province or city, he/she shall go through the formalities of cross-regional medical service registration as required. The healthcare security administration agency shall provide direct settlement services for the insured individual seeking medical services at a designated medical institution in the registered location.

Article 47

Employers and the insured individuals have the right to inquire about their corresponding basic medical insurance payment records and personal rights records and request the healthcare security administration agencies to provide healthcare security consultation and related services.

Article 48

The municipal healthcare security department shall establish a city-wide healthcare security information system in accordance with the nationally unified technical standards and specifications. The information systems of the designated medical and pharmaceutical institutions shall effectively connect with the healthcare security information system, use nationally unified healthcare security information service codes, and accurately upload data information.

The healthcare security, finance, and health departments shall promote the application of healthcare security electronic vouchers and electronic invoices, advance healthcare security mobile payments and electronic prescription circulation, and provide the insured individual with accurate, standardized, and convenient medical and pharmaceutical services.

Article 49

The healthcare security, health, civil affairs, human resources and social security, education, public security, veterans affairs, and judicial administration departments shall, based on the municipal big data resource platform, promptly share in accordance with law the personal identity and participation status information related to healthcare security administration and services, such as birth, death, household registration, and student status.

The healthcare security department shall supervise the medical service behavior and medical expenses included in the payment scope of the healthcare security fund, establish and improve various forms of inspection systems such as daily inspection, special inspection and surprise inspection, and carry out administrative law enforcement work on healthcare security in accordance with law.

Article 50

An insured individual's healthcare security electronic medical data, after authorization by the person himself/herself, may be used for commercial health insurance product claims. The exploration of direct compensation by commercial health insurance at designated medical institutions shall be promoted to improve the compensation efficiency.

Chapter VI Supervision and Administration

Article 51

The municipal and district's people's governments shall improve the supervision and administration mechanism for the healthcare security fund, strengthen supervision and administration capacity building as needed to maintain the safety of the healthcare security fund, and promote cross-departmental comprehensive supervision and administration.

The departments of healthcare security, public health, medical products administration, taxation, civil affairs, human resources and social security, financial regulation, market regulation, and public security shall establish communication, coordination, joint law enforcement, and case transfer mechanisms for healthcare security fund supervision and administration. These departments shall collaborate effectively, ensuring close cooperation and enhancing the division of responsibilities while promoting joint efforts in fulfilling their respective duties.

Article 52

The healthcare security department may take the following measures during the supervision and inspections:

1. conducting on-site inspections;

2. inquiring relevant personnel;

3. requesting the inspected party to provide documents and materials and the carriers thereof related to the inspection and provide explanations;

4. requesting the inspected party to explain the data retrieved from the relevant healthcare security information system;

5. collecting relevant information and materials through recording, audio, video, photography, copying or other methods;

6. sealing materials that may be transferred, concealed or destroyed;

7. engaging qualified accounting firms or other third-party institutions or professionals to assist in the inspections; 

8. and other measures provided by laws, rules or regulations.

Article 53

The healthcare security administration agencies shall monitor in real time the number of accumulative monthly outpatient and emergency visits and the basic medical insurance expenses incurred by the insured individuals in the designated medical institutions, as well as the basic medical insurance expenses incurred by their accumulative monthly medicine purchase at the designated retail pharmacies.

If it is found in the real-time monitoring or through other methods that a matter mentioned in the preceding Paragraph exceeds the prescribed limit and is suspected of defrauding the healthcare security fund, and the insured individual refuses to cooperate in the investigation, the healthcare security department may request the healthcare security administration agency to suspend the online settlement therefor. The medical expenses incurred during the suspension period shall be prepaid in full by the said insured individual.

Insured individuals shall cooperate with the investigation, and provide explanations and submit relevant materials as required. If the insured individual's violation of laws, rules or regulations is found in the investigation, he/she shall be handled in accordance with the relevant provisions. If no such violation is found, the healthcare security department shall promptly request the healthcare security administration agency to resume the online settlement therefor and reimburse prepaid medical expenses in accordance with the provisions.

Article 54

The healthcare security department may use the methods of healthcare security intelligent monitoring and big data analysis and rely on the platform of the Integrated Online Administration for city operation, etc., to establish a healthcare security intelligent monitoring system covering pre-event, in-process and post-event whole processes, and improve the supervision and administration efficiency in areas such as clue discovery, investigation and evidence collection, violation handling, and result application.

Article 55

The healthcare security department shall supervise and administrate cross-regional medical expenses in accordance with the national provisions, using cross-regional settlement data exchange, joint and mutual medical expense review, and coordinated mutual investigation of reported clues to supervise the people seeking cross-region medical treatment.

Article 56

The municipal healthcare security department shall, in accordance with law, establish a healthcare security credit evaluation system, implement hierarchical and classified supervision and administration based on the credit evaluation results, collect public credit information in the healthcare security field onto the municipal public credit information service platform and conduct credit incentives and discredit constraints.

Article 57

For relevant staff involved in the use of the healthcare security fund in designated medical institutions who violate the service agreements or service commitments, the healthcare security administration agencies shall implement scoring management in accordance with the provisions of the State and this Municipality.

Article 58

The standing committees of the municipal and district people's congresses shall strengthen supervision over the healthcare security work within their respective administrative areas by hearing and deliberating on the special work reports, conducting law enforcement inspections, and other relevant means.

Article 59

This Municipality encourages and supports social participation in the public supervision of healthcare security. The healthcare security department may engage social supervisors to participate in the supervision of the healthcare security fund.

Any organization or individual has the right to report and complain about illegal acts that harm the healthcare security fund. The healthcare security department shall establish accessible channels for reporting and complaints, handle such reports and complaints promptly in accordance with law, keep the informants' information confidential, protect their legitimate rights and interests, and reward them for their verified reports in accordance with the provisions of the State and this Municipality.

Chapter VII Legal Liability

Article 60

Where laws or administrative rules have already provided for handling the acts that violate these Regulations, such provisions shall prevail.

Article 61

If a designated assessment institution or designated nursing institution violates Paragraph 2 or 3 of Article 22 of these Regulations and engages in any of the following acts during long-term care insurance expense settlement, the healthcare security department shall order corrections and may summon the relevant responsible person for a talk; if losses are caused to the healthcare security fund, the institution shall be ordered to return the funds and shall be subject to a fine of not less than one time but not more than two times the amount of the loss incurred. If corrections are refused or serious consequences occur due to the violation, the said institution shall be ordered to suspend the directly responsible staff from providing assessment or nursing services related to the healthcare security fund use for six months to one year:

1. The assessment level determined by the designated assessment institution does not match the insured individual’s actual condition;

2. The designated nursing institution fails to verify the insured individual’s identity as required;

3. The designated nursing institution fails to formulate a service plan according to the assessment level and service items;

4. The designated nursing institution fails to provide services according to the service items, standards, duration, and frequency;

5. The designated nursing institution exceeds the service fee standards for long-term care insurance expense settlement; 

6. Or other illegal acts causing healthcare security fund losses.

If a designated assessment institution or designated nursing institution engages in any of the acts mentioned in the preceding Paragraph with the purpose of defrauding the healthcare security fund, or defrauds healthcare security fund payments by forging or altering nursing records, medical history records, accounts, or electronic information, fabricating services, or other means, the healthcare security department shall order the return of the misappropriated payments, impose a fine of not less than two times but not more than five times the amount defrauded, and order the designated assessment institution or designated nursing institution to suspend the directly responsible staff from providing assessment or nursing services related to the healthcare security fund use for a period of six months to one year.

Article 62

If an insured individual violates Paragraph 4 of Article 22 of these Regulations, and provides false information or materials with the purpose of defrauding the healthcare security fund during the application or receipt of long-term care insurance assessment or nursing services, the healthcare security department shall order the return of the fund and impose a fine of not less than two times but not more than five times the amount defrauded, and suspend his/her long-term care insurance online settlement for a period of three to twelve months.

If an insured individual repeatedly and excessively purchases medicine significantly exceeding the prescribed limits, causing losses to the healthcare security fund, but no case of his/her defrauding the healthcare security fund is found, the healthcare security department shall order corrections and the return of the relevant expenses paid by the healthcare security fund. Upon correction by the insured individuals, the healthcare security department shall request the healthcare security administration agency to promptly resume the online settlement. The medical expenses prepaid by the insured individual shall be settled according to the provisions.

Article 63

If a designated medical institution’s procurement or use quantity of medicines or medical consumables has discrepancies with the healthcare security fund settlement accounts, which violates Paragraph 2 of Article 32 of these Regulations, and no other illegal circumstances as prescribed by laws, rules and regulations are found, the healthcare security department shall order it to rectify and may summon the relevant responsible persons for a talk. If the institution fails to rectify, a fine of not less than 10,000 yuan but not more than 50,000 yuan shall be imposed.

Where a designated medical institution violates the provisions of Paragraph 2 of Article 32 of these Regulations by requiring insured individuals to bear expenses that should be covered by the healthcare security fund, the healthcare security department shall order it to rectify and may issue a warning; if the circumstances are serious, a fine of not less than 20,000 yuan but not more than 50,000 yuan shall be imposed.

Article 64

If the healthcare security department, healthcare security administration agency, or their staff violate these Regulations and fail to perform relevant administration or agency duties, their unit or superior competent department shall order them to rectify; if they are found to have neglected their duties, abused their power, or engaged in malpractice for personal gain, the directly responsible person-in-charge and other directly responsible persons shall be subject to disciplinary sanctions in accordance with law; if their wrongdoing constitutes a crime, they shall be prosecuted for criminal liability in accordance with law.

Article 65

In the process of investigating and handling illegal activities related to healthcare security, if the healthcare security department or other relevant departments find such activities are suspected of constituting a criminal offense, they shall transfer the case to the public security organ in accordance with the provisions. If it constitutes a violation of the law on public security administration, the public security organ shall impose administrative penalties for public security in accordance with law. If it constitutes a criminal offense, criminal liability shall be pursued in accordance with law.

Chapter VIII Supplementary Provision

Article 66

These Regulations shall be effective as of March 1, 2025.