Published by ChinaMNC · Kaijiang

Dazhou's Urban and Rural Resident Basic Medical Insurance Measures: A Practical Guide for Foreign Founders

A concise overview of Dazhou's resident medical insurance rules, covering enrollment, premiums, benefits, and compliance for foreign founders operating in China.

Overview of Dazhou's Resident Medical Insurance Framework

For foreign founders establishing a presence in Dazhou, understanding local social insurance obligations is essential. The Dazhou Municipal People's Government has issued measures governing the Urban and Rural Resident Basic Medical Insurance (居民医保). These rules aim to improve the resident insurance system, standardize service management, protect insured persons' basic medical rights, and enhance medical security capacity and service levels. The measures are grounded in national laws such as the Social Insurance Law and the Regulations on the Supervision and Management of the Use of Medical Security Funds, as well as policy documents from the State Council and national and provincial medical security authorities.

Unified Administration

The measures emphasize city-wide unification across eight key areas: enrollment scope, premium standards, fund management, medical insurance catalog, benefit levels, designated medical institution management, administrative services, and information systems. This means foreign founders can expect consistent rules throughout Dazhou.

Who Is Eligible to Enroll?

Resident medical insurance covers individuals who are not enrolled in the employee basic medical insurance and do not enjoy other national medical security benefits. Importantly, double enrollment is prohibited: those already covered by basic medical insurance cannot enroll again. Foreign founders should note that their Chinese employees may be covered under employee insurance, while others such as family members or local hires not on employee insurance may fall under resident insurance.

Premium Contributions and Government Subsidies

Enrollees pay individual premiums as prescribed, and the government provides subsidies. Government subsidy funds are shared among different levels of government. Based on the national annual fiscal subsidy standard, after deducting central and provincial subsidies, the local share is borne entirely by county-level finance in counties with expanded authority (扩权县), while in non-expanded counties (districts), the municipal finance bears 20% and county finance 80%. County governments must include their share in annual fiscal budgets and remit 50% by the end of June and the full amount by the end of December to the municipal social insurance fund fiscal account.

Each year, the municipal medical security, finance, and taxation departments announce the individual premium standard for the coming year, taking into account national and provincial regulations, local economic and social development, and fund operations.

Subsidies for Vulnerable Groups

For urban and rural residents with Dazhou household registration who are in extreme poverty, orphans, minimum living guarantee recipients, or eligible targets for preventing return to poverty, categorized subsidies are provided according to relevant regulations. Severely disabled persons and entitled groups (优抚对象) who have genuine difficulty paying individual premiums may receive assistance from the government of their registered residence.

Covered Benefits

Resident medical insurance benefits include ordinary outpatient care, outpatient chronic and special diseases, outpatient medication security for hypertension and diabetes (the "two diseases"), inpatient medical care, and maternity medical security, as well as critical illness insurance benefits as prescribed. The scope of fund payments must comply with national and provincial catalogs for drugs, medical consumables, and medical service items.

Outpatient and Chronic Disease Coverage

The municipal medical security and finance departments reasonably determine the level of coverage for ordinary outpatient and outpatient chronic and special disease expenses, based on disease patterns, insured persons' needs, and fund capacity.

Hypertension and Diabetes Outpatient Medication

Insured patients receiving medication for the "two diseases" but not meeting the criteria for outpatient chronic and special disease coverage are included in the "two diseases" outpatient medication security. For drugs for lowering blood pressure and blood sugar within the medical insurance policy scope, there is no deductible (起付标准), and the pooled fund pays 90%. The annual maximum payment limit is 200 yuan for hypertension, 300 yuan for diabetes, and 500 yuan for those with both conditions.

Inpatient Benefits

Inpatient medical expenses at designated medical institutions are settled per admission. Total medical expenses minus self-pay and first self-pay portions, after deducting the deductible, are paid proportionally. Deductibles are: 100 yuan at township health centers and community health service centers (stations) within Dazhou; 400 yuan at other secondary and below medical institutions; 600 yuan at tertiary medical institutions. For medical institutions outside Dazhou but within Sichuan Province (including Chongqing), the deductible is 1,200 yuan; outside the province, 1,800 yuan. For self-initiated out-of-area medical treatment, deductibles increase to 1,500 yuan within the province (including Chongqing) and 2,000 yuan outside the province. For two or more hospitalizations in one insurance year, the deductible is reduced by 50 yuan each time, but not below 50 yuan.

The pooled fund payment proportions are: 90% at township health centers and community health service centers (stations) within Dazhou; 75% at other secondary and below medical institutions; and 70% at tertiary medical institutions.

For two-way referral within the city, medical expenses are calculated as one hospitalization. Covered inpatient expenses are subject to the deductible of the higher-tier institution and paid segmentally according to the actual institution's payment proportion.

Bed fees are capped: 15 yuan per bed per day at tertiary institutions, 12 yuan at secondary, and 10 yuan at primary and below. Laminar flow clean wards, intensive care units, and special protection wards follow relevant regulations. For single-use Class B consumables and Class B diagnostic and treatment items costing less than 2,000 yuan, the first self-pay is 20%; for those over 2,000 yuan, 30%; within one hospitalization period, the amount included in fund payment shall not exceed 10,000 yuan.

Maternity Benefits

For insured residents' inpatient medical expenses related to childbirth within the medical insurance policy scope, there is no deductible, and actual expenses are paid within the limit. A fixed subsidy is provided for prenatal examination expenses. The municipal medical security and finance departments reasonably determine the security standards.

Family Sickbeds

With approval from medical security departments, township health centers and community health service centers (stations) may establish family sickbeds for eligible insured persons. Covered medical expenses are paid according to the corresponding inpatient proportion.

Exclusions and Waiting Periods

The measures list expenses not payable by the basic medical insurance fund, including other expenses stipulated by the state. Temporary adjustments may be made through legal procedures if significant economic and social impacts occur.

Starting from 2025, except for special groups such as newborns, those who fail to enroll during the centralized enrollment period or fail to enroll continuously will have a fixed waiting period of 3 months after enrollment. For each additional year of discontinuous enrollment, an additional variable waiting period of 1 month is added. Insured persons can repair the variable waiting period by paying premiums: each additional year of payment reduces the variable waiting period by 1 month. For those with continuous gaps of 4 years or more, after repair, the total of fixed and variable waiting periods shall be no less than 6 months.

Insured persons who have continuously participated in basic medical insurance for 2 years or more and paid as required, and who switch from employee insurance to resident insurance due to employment or personal status changes, with an interruption of no more than 3 months, can enjoy medical insurance benefits normally after payment, and benefits during the interruption period are retroactively enjoyed as prescribed. If the interruption exceeds 3 months, a waiting period is set as prescribed.

Newborns enrolled in the resident medical insurance for the year of birth within 90 days from birth enjoy benefits from the date of birth; if enrolled after 90 days, benefits start from the date of payment.

Designated Medical Institutions and Compliance

Resident medical insurance adopts management of designated medical institutions for medical treatment and drug purchases. The medical insurance agency determines designated institutions, signs service agreements, provides administrative services, conducts agreement management and assessments, and implements dynamic management. Designated institutions must assign dedicated personnel to cooperate with the medical insurance agency in medical service management. Insured persons' medical expenses must be separately accounted for by financial personnel and provided truthfully, promptly, and accurately to the medical insurance agency as required.

Foreign founders operating in Dazhou should ensure compliance with these rules if they participate in or contribute to resident medical insurance for eligible staff or family members. Understanding the enrollment scope, premium obligations, benefit structures, and waiting periods will help avoid unexpected gaps in coverage.

This summary is based on information published by the relevant Chinese government website and is general information, not legal or tax advice.