KYB CHINA(2020年12月9日国务院第117次常务会议通过 2021年1月15日中华人民共和国国务院令第735号公布 自2021年5月1日起施行)
(Adopted at the 117th executive meeting of the State Council on December 9, 2020, promulgated by Order No. 735 of the State Council of the People's Republic of China on January 15, 2021, and effective as of May 1, 2021)
总 则
General Provisions
为了加强医疗保障基金使用监督管理，保障基金安全，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。
This Regulation is formulated in accordance with the Social Insurance Law of the People's Republic of China and other relevant laws and regulations, with a view to strengthening the supervision and administration of the use of medical security funds, ensuring the safety of the funds, promoting the effective use of the funds, and safeguarding the legitimate rights and interests of citizens in medical security.
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。
This Regulation applies to the use and supervision and administration of medical security funds such as basic medical insurance (including maternity insurance) funds and medical assistance funds within the territory of the People's Republic of China.
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。
The use of medical security funds shall adhere to the principle of people's health as the center, ensure that the level of protection is commensurate with the level of economic and social development, and follow the principles of legality, safety, openness, and convenience.
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。
The supervision and administration of the use of medical security funds shall combine government supervision, social supervision, industry self-discipline, and individual good faith.
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。
People's governments at or above the county level shall strengthen leadership over the supervision and administration of the use of medical security funds, establish and improve the supervision and administration mechanism and the law enforcement system for fund supervision, strengthen the capacity building for the supervision and administration of the use of medical security funds, and provide guarantees for the supervision and administration of the use of medical security funds.
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。
The medical security administrative department of the State Council shall be in charge of the supervision and administration of the use of medical security funds nationwide. Other relevant departments of the State Council shall be responsible for the supervision and administration of the use of medical security funds within their respective duties.
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。
The medical security administrative departments of local people's governments at or above the county level shall be responsible for the supervision and administration of the use of medical security funds within their respective administrative regions. Other relevant departments of local people's governments at or above the county level shall be responsible for the supervision and administration of the use of medical security funds within their respective duties.
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。
The State encourages and supports news media to carry out public welfare publicity of medical security laws, regulations, and medical security knowledge, and to conduct public opinion supervision over the use of medical security funds. Relevant medical security publicity reports shall be truthful and fair.
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。
The people's governments at or above the county level and their medical security and other administrative departments shall, by means of soliciting opinions in writing, holding symposiums, etc., listen to the opinions of deputies to the people's congresses, members of the Chinese People's Political Consultative Conference, representatives of insured persons, etc., on the use of medical security funds, smooth the channels for social supervision, and encourage and support all sectors of society to participate in the supervision of the use of medical security funds.
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。
Medical institutions, drug business units (hereinafter collectively referred to as medical and pharmaceutical institutions) and other units and medical and pharmaceutical health industry associations shall strengthen industry self-discipline, standardize medical and pharmaceutical service behavior, promote industry norms and self-restraint, and guide the lawful and reasonable use of medical security funds.
基金使用
Fund Use
医疗保障基金使用应当符合国家规定的支付范围。
The use of medical security funds shall conform to the payment scope prescribed by the state.
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。
The payment scope of medical security funds shall be organized and formulated by the medical security administrative department of the State Council in accordance with the law. The people's governments of provinces, autonomous regions, and municipalities directly under the Central Government shall, in accordance with the authority and procedures prescribed by the state, supplement and formulate specific items and standards for the payment of medical security funds within their respective administrative regions, and report them to the medical security administrative department of the State Council for recordation.
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。
The state establishes and improves a unified national medical security handling management system, provides standardized and normalized medical security handling services, and achieves full coverage at the provincial, municipal, county, township (street), and village (community) levels.
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。
Medical security handling institutions shall establish and improve business, financial, safety, and risk management systems, do a good job in service agreement management, expense monitoring, fund allocation, treatment review and payment, etc., and regularly disclose to the public the income, expenditure, balance, etc., of medical security funds, and accept social supervision.
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。
Medical security handling institutions shall establish a collective negotiation mechanism with designated medical and pharmaceutical institutions, reasonably determine the budget amount and allocation time limit of medical security funds for designated medical and pharmaceutical institutions, and, according to the needs of protecting public health and management services, negotiate and sign service agreements with designated medical and pharmaceutical institutions, standardize medical and pharmaceutical service behavior, and clarify the acts that violate the service agreement and their responsibilities.
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。
Medical security handling institutions shall promptly announce to the public the list of designated medical and pharmaceutical institutions that have signed service agreements.
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。
The medical security administrative department shall strengthen supervision over the conclusion and performance of service agreements.
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。
Medical security agencies shall, in accordance with the service agreement, settle and disburse medical security funds in a timely manner.
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。
Designated medical institutions shall provide medical services in accordance with regulations, improve service quality, use medical security funds reasonably, and safeguard citizens' health rights.
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。
If a designated medical institution violates the service agreement, the medical security agency may urge it to perform the agreement, suspend or withhold payment, recover illegal fees, suspend the medical services involving medical security funds of the responsible personnel or their department, or even terminate the service agreement; the designated medical institution and its responsible personnel have the right to make statements and defenses.
医疗保障经办机构违反服务协议的，定点医药机构有权要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。
If a medical security agency violates the service agreement, the designated medical institution has the right to request correction or refer the matter to the medical security administrative department for coordination and supervision, or may apply for administrative reconsideration or file an administrative lawsuit in accordance with the law.
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。
Designated medical institutions shall establish internal management systems for the use of medical security funds, assign specialized institutions or personnel to manage the use of medical security funds, and establish a sound assessment and evaluation system.
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。
Designated medical institutions shall organize training on systems and policies related to medical security funds, regularly inspect the use of medical security funds within their institutions, and promptly correct non-standard use of medical security funds.
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。
Designated medical institutions and their staff shall implement the management regulations for real-name medical treatment and drug purchase, verify the medical security credentials of insured persons, provide reasonable and necessary medical services in accordance with diagnosis and treatment norms, issue truthful expense documents and relevant materials to insured persons, and shall not split hospitalization, hang bed hospitalization, over-treat, over-examine, split prescriptions, over-prescribe, repeat prescriptions, charge repeatedly, charge above standard, split item charges, swap drugs, medical consumables, diagnosis and treatment items, and service facilities, or induce or assist others to seek medical treatment or purchase drugs under false names or fraudulently.
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。
Designated medical institutions shall ensure that expenses paid by medical security funds fall within the prescribed payment scope; except for emergency, rescue, and other special circumstances, providing medical services outside the payment scope of medical security funds shall require the consent of the insured person or their close relatives or guardians.
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。
Designated medical institutions shall keep financial accounts, accounting vouchers, prescriptions, medical records, treatment and examination records, expense details, drug and medical consumables inventory records, and other materials in accordance with regulations, timely and accurately transmit data related to the use of medical security funds through the medical security information system, report information required for the supervision and administration of medical security fund use to the medical security administrative department, disclose medical expenses, expense structure, and other information to the public, and accept social supervision.
参保人员应当持本人医疗保障凭证就医、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。
Insured persons shall hold their own medical security credentials for medical treatment and drug purchase, and proactively present them for inspection. Insured persons have the right to request designated medical institutions to issue truthful expense documents and relevant materials.
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。
Insured persons shall properly keep their own medical security credentials to prevent others from using them under false pretenses. If it is necessary to entrust another person to purchase medicine due to special reasons, the identity certificates of both the principal and thetrustee shall be provided.
参保人员应当按照规定享受医疗保障待遇，不得重复享受。
Insured persons shall enjoy medical security benefits in accordance with regulations and shall not enjoy duplicate benefits.
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。
Insured persons have the right to request medical security agencies to provide medical security consulting services and to propose improvements regarding the use of medical security funds.
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。
In the process of using medical security funds, administrative departments such as medical security, health, medical security agencies, designated medical institutions, and their staff shall not accept bribes or obtain other illegal income.
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利益。
Insured persons shall not use their opportunity to enjoy medical security benefits to resell drugs, accept cash refunds, physical goods, or obtain other illegal benefits.
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。
Designated medical institutions shall not facilitate insured persons in using their opportunity to enjoy medical security benefits to resell drugs, accept cash refunds, physical goods, or obtain other illegal benefits.
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。
Medical security agencies, designated medical institutions, and other units, as well as their staff and insured persons, shall not defraud medical security funds by forging, altering, concealing, altering, or destroying medical documents, medical certificates, accounting vouchers, electronic information, or other relevant materials, or by fabricating medical service projects.
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。
Medical security funds shall be used for designated purposes only, and no organization or individual may embezzle or misappropriate them.
监督管理
Supervision and Administration
医疗保障、卫生健康、中医药、市场监督管理、财政、审计、公安等部门应当分工协作、相互配合，建立沟通协调、案件移送等机制，共同做好医疗保障基金使用监督管理工作。
Departments such as medical security, health, traditional Chinese medicine, market supervision, finance, audit, and public security shall cooperate and coordinate with each other, establish mechanisms for communication, coordination, and case transfer, and jointly carry out the supervision and administration of the use of medical security funds.
医疗保障行政部门应当加强对纳入医疗保障基金支付范围的医疗服务行为和医疗费用的监督，规范医疗保障经办业务，依法查处违法使用医疗保障基金的行为。
The medical security administrative department shall strengthen supervision over medical service behaviors and medical expenses included in the scope of medical security fund payment, standardize medical security administrative services, and investigate and punish illegal use of medical security funds in accordance with the law.
国务院医疗保障行政部门负责制定服务协议管理办法，规范、简化、优化医药机构定点申请、专业评估、协商谈判程序，制作并定期修订服务协议范本。
The medical security administrative department of the State Council is responsible for formulating measures for the management of service agreements, standardizing, simplifying, and optimizing procedures for medical institution application, professional evaluation, and negotiation, and producing and regularly revising model service agreements.
国务院医疗保障行政部门制定服务协议管理办法，应当听取有关部门、医药机构、行业协会、社会公众、专家等方面意见。
When formulating measures for the management of service agreements, the medical security administrative department of the State Council shall solicit opinions from relevant departments, medical institutions, industry associations, the public, and experts.
医疗保障行政部门应当加强与有关部门的信息交换和共享，创新监督管理方式，推广使用信息技术，建立全国统一、高效、兼容、便捷、安全的医疗保障信息系统，实施大数据实时动态智能监控，并加强共享数据使用全过程管理，确保共享数据安全。
The medical security administrative department shall strengthen information exchange and sharing with relevant departments, innovate supervision methods, promote the use of information technology, establish a national unified, efficient, compatible, convenient, and secure medical security information system, implement real-time dynamic intelligent monitoring of big data, and strengthen the whole-process management of shared data use to ensure the security of shared data.
医疗保障行政部门应当根据医疗保障基金风险评估、举报投诉线索、医疗保障数据监控等因素，确定检查重点，组织开展专项检查。
The medical security administrative department shall determine inspection priorities based on factors such as medical security fund risk assessment, reporting and complaint clues, and medical security data monitoring, and organize special inspections.
医疗保障行政部门可以会同卫生健康、中医药、市场监督管理、财政、公安等部门开展联合检查。
The medical security administrative department may conduct joint inspections with departments such as health, traditional Chinese medicine, market supervision, finance, and public security.
对跨区域的医疗保障基金使用行为，由共同的上一级医疗保障行政部门指定的医疗保障行政部门检查。
For cross-regional use of medical security funds, the inspection shall be carried out by the medical security administrative department designated by the common higher-level medical security administrative department.
医疗保障行政部门实施监督检查，可以采取下列措施：
When conducting supervision and inspection, the medical security administrative department may take the following measures:
（一）进入现场检查；
(1) Enter the site for inspection;
（二）询问有关人员；
(2) Inquire relevant personnel;
（三）要求被检查对象提供与检查事项相关的文件资料，并作出解释和说明；
(3) Require the inspected entity to provide documents and materials related to the inspection matters and to make explanations and clarifications;
（四）采取记录、录音、录像、照相或者复制等方式收集有关情况和资料；
(4) Collect relevant information and materials by means of recording, audio recording, video recording, photography, or reproduction;
（五）对可能被转移、隐匿或者灭失的资料等予以封存；
(5) Seal up materials that may be transferred, concealed, or destroyed;
（六）聘请符合条件的会计师事务所等第三方机构和专业人员协助开展检查；
(6) Engage qualified accounting firms and other third-party institutions and professionals to assist in carrying out inspections;
（七）法律、法规规定的其他措施。
(7) Other measures provided by laws and regulations.
医疗保障行政部门可以依法委托符合法定条件的组织开展医疗保障行政执法工作。
The medical security administrative department may, in accordance with the law, entrust qualified organizations to carry out medical security administrative law enforcement work.
开展医疗保障基金使用监督检查，监督检查人员不得少于2人，并且应当出示执法证件。
When conducting supervision and inspection of the use of medical security funds, there shall be no fewer than two inspectors, and they shall present their law enforcement credentials.
医疗保障行政部门进行监督检查时，被检查对象应当予以配合，如实提供相关资料和信息，不得拒绝、阻碍检查或者谎报、瞒报。
When the medical security administrative department conducts supervision and inspection, the inspected entity shall cooperate, truthfully provide relevant materials and information, and shall not refuse or obstruct the inspection or make false reports or concealments.
定点医药机构涉嫌骗取医疗保障基金支出的，在调查期间，医疗保障行政部门可以采取增加监督检查频次、加强费用监控等措施，防止损失扩大。定点医药机构拒不配合调查的，经医疗保障行政部门主要负责人批准，医疗保障行政部门可以要求医疗保障经办机构暂停医疗保障基金结算。经调查，属于骗取医疗保障基金支出的，依照本条例第四十条的规定处理；不属于骗取医疗保障基金支出的，按照规定结算。
If a designated medical institution is suspected of fraudulently obtaining medical security fund expenditures, during the investigation period, the medical security administrative department may take measures such as increasing the frequency of supervision and inspection and strengthening cost monitoring to prevent the expansion of losses. If the designated medical institution refuses to cooperate with the investigation, with the approval of the principal person in charge of the medical security administrative department, the medical security administrative department may require the medical security agency to suspend the settlement of medical security funds. After investigation, if it is determined to be fraudulent obtaining of medical security fund expenditures, it shall be handled in accordance with Article 40 of these Regulations; if it is not fraudulent obtaining of medical security fund expenditures, settlement shall be made in accordance with the regulations.
参保人员涉嫌骗取医疗保障基金支出且拒不配合调查的，医疗保障行政部门可以要求医疗保障经办机构暂停医疗费用联网结算。暂停联网结算期间发生的医疗费用，由参保人员全额垫付。经调查，属于骗取医疗保障基金支出的，依照本条例第四十一条的规定处理；不属于骗取医疗保障基金支出的，按照规定结算。
If an insured person is suspected of fraudulently obtaining medical security fund expenditures and refuses to cooperate with the investigation, the medical security administrative department may require the medical security agency to suspend the online settlement of medical expenses. Medical expenses incurred during the period of suspension of online settlement shall be fully prepaid by the insured person. After investigation, if it is determined to be fraudulent obtaining of medical security fund expenditures, it shall be handled in accordance with Article 41 of these Regulations; if it is not fraudulent obtaining of medical security fund expenditures, settlement shall be made in accordance with the regulations.
医疗保障行政部门对违反本条例的行为作出行政处罚或者行政处理决定前，应当听取当事人的陈述、申辩；作出行政处罚或者行政处理决定，应当告知当事人依法享有申请行政复议或者提起行政诉讼的权利。
Before making an administrative penalty or administrative handling decision for a violation of this Regulation, the medical security administrative department shall hear the statements and defenses of the party concerned; when making an administrative penalty or administrative handling decision, it shall inform the party concerned of the right to apply for administrative reconsideration or initiate administrative litigation in accordance with the law.
医疗保障等行政部门、医疗保障经办机构、会计师事务所等机构及其工作人员，不得将工作中获取、知悉的被调查对象资料或者相关信息用于医疗保障基金使用监督管理以外的其他目的，不得泄露、篡改、毁损、非法向他人提供当事人的个人信息和商业秘密。
Medical security administrative departments, medical security agencies, accounting firms, and other institutions and their staff shall not use the materials or related information of the investigated subjects obtained or known in the course of work for purposes other than the supervision and administration of the use of medical insurance funds, and shall not disclose, tamper with, destroy, or illegally provide others with the personal information and trade secrets of the parties concerned.
国务院医疗保障行政部门应当建立定点医药机构、人员等信用管理制度，根据信用评价等级分级分类监督管理，将日常监督检查结果、行政处罚结果等情况纳入全国信用信息共享平台和其他相关信息公示系统，按照国家有关规定实施惩戒。
The medical security administrative department of the State Council shall establish a credit management system for designated medical institutions, personnel, etc., conduct graded and classified supervision and management based on credit evaluation grades, and incorporate daily supervision and inspection results, administrative penalty results, etc., into the national credit information sharing platform and other relevant information disclosure systems, and implement disciplinary actions in accordance with relevant national regulations.
医疗保障行政部门应当定期向社会公布医疗保障基金使用监督检查结果，加大对医疗保障基金使用违法案件的曝光力度，接受社会监督。
The medical security administrative department shall regularly announce to the public the results of supervision and inspection of the use of medical insurance funds, increase the exposure of illegal cases involving the use of medical insurance funds, and accept social supervision.
任何组织和个人有权对侵害医疗保障基金的违法违规行为进行举报、投诉。
Any organization or individual has the right to report and complain about illegal or non-compliant acts that infringe on medical insurance funds.
医疗保障行政部门应当畅通举报投诉渠道，依法及时处理有关举报投诉，并对举报人的信息保密。对查证属实的举报，按照国家有关规定给予举报人奖励。
The medical security administrative department shall smooth the reporting and complaint channels, handle relevant reports and complaints in a timely manner in accordance with the law, and keep the informant's information confidential. For verified reports, the informant shall be rewarded in accordance with relevant national regulations.
法律责任
Legal Liability
医疗保障经办机构有下列情形之一的，由医疗保障行政部门责令改正，对直接负责的主管人员和其他直接责任人员依法给予处分：
If a medical security agency has any of the following circumstances, the medical security administrative department shall order it to make corrections, and impose sanctions on the directly responsible supervisors and other directly responsible personnel in accordance with the law:
（一）未建立健全业务、财务、安全和风险管理制度；
(1) Failure to establish a sound business, financial, safety, and risk management system;
（二）未履行服务协议管理、费用监控、基金拨付、待遇审核及支付等职责；
(2) Failure to perform duties such as service agreement management, expense monitoring, fund allocation, benefit review, and payment;
（三）未定期向社会公开医疗保障基金的收入、支出、结余等情况。
(3) Failing to regularly disclose to the public the income, expenditure, and balance of the medical security fund.
医疗保障经办机构通过伪造、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，骗取医疗保障基金支出的，由医疗保障行政部门责令退回，处骗取金额2倍以上5倍以下的罚款，对直接负责的主管人员和其他直接责任人员依法给予处分。
Where a medical security agency fraudulently obtains medical security fund expenditures by forging, altering, concealing, tampering with, or destroying relevant materials such as medical documents, medical certificates, accounting vouchers, electronic information, or by fabricating medical service projects, the medical security administrative department shall order the return of the funds and impose a fine of not less than 2 times but not more than 5 times the amount fraudulently obtained; the directly responsible supervisors and other directly responsible personnel shall be given sanctions according to law.
定点医药机构有下列情形之一的，由医疗保障行政部门责令改正，并可以约谈有关负责人；造成医疗保障基金损失的，责令退回，处造成损失金额1倍以上2倍以下的罚款；拒不改正或者造成严重后果的，责令定点医药机构暂停相关责任部门6个月以上1年以下涉及医疗保障基金使用的医药服务；违反其他法律、行政法规的，由有关主管部门依法处理：
Where a designated medical institution has any of the following circumstances, the medical security administrative department shall order correction and may interview the responsible person; if losses are caused to the medical security fund, it shall order the return of the funds and impose a fine of not less than 1 time but not more than 2 times the amount of losses; if the institution refuses to correct or causes serious consequences, it shall order the designated medical institution to suspend the relevant responsible department's medical services involving the use of medical security funds for a period of not less than 6 months but not more than 1 year; if other laws or administrative regulations are violated, the relevant competent authorities shall handle the matter according to law:
（一）分解住院、挂床住院；
(1) Splitting hospitalization or bed occupancy without medical necessity;
（二）违反诊疗规范过度诊疗、过度检查、分解处方、超量开药、重复开药或者提供其他不必要的医药服务；
(2) Providing excessive diagnosis, excessive examination, splitting prescriptions, over-prescribing, duplicate prescribing, or other unnecessary medical services in violation of diagnosis and treatment standards;
（三）重复收费、超标准收费、分解项目收费；
(3) Duplicate charging, over-standard charging, or splitting items for charging;
（四）串换药品、医用耗材、诊疗项目和服务设施；
(4) Switching drugs, medical consumables, diagnosis and treatment items, and service facilities;
（五）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；
(5) Facilitating insured persons to resell drugs, accept cash or in-kind returns, or obtain other illegal benefits by taking advantage of their medical security benefits;
（六）将不属于医疗保障基金支付范围的医药费用纳入医疗保障基金结算；
(6) Including medical expenses not covered by the medical security fund into the medical security fund settlement;
（七）造成医疗保障基金损失的其他违法行为。
(7) Other illegal acts causing losses to the medical security fund.
定点医药机构有下列情形之一的，由医疗保障行政部门责令改正，并可以约谈有关负责人；拒不改正的，处1万元以上5万元以下的罚款；违反其他法律、行政法规的，由有关主管部门依法处理：
If a designated medical institution has any of the following circumstances, the medical security administrative department shall order correction and may interview the responsible person; if correction is refused, a fine of not less than 10,000 yuan but not more than 50,000 yuan shall be imposed; if other laws or administrative regulations are violated, the relevant competent department shall handle it according to law:
（一）未建立医疗保障基金使用内部管理制度，或者没有专门机构或者人员负责医疗保障基金使用管理工作；
(1) Failure to establish an internal management system for the use of medical security funds, or failure to have a specialized institution or personnel responsible for the management of the use of medical security funds;
（二）未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；
(2) Failure to keep financial accounts, accounting vouchers, prescriptions, medical records, treatment and examination records, expense details, records of drug and medical consumable inventory in and out, and other materials as required;
（三）未按照规定通过医疗保障信息系统传送医疗保障基金使用有关数据；
(3) Failure to transmit relevant data on the use of medical security funds through the medical security information system as required;
（四）未按照规定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；
(4) Failure to report information required for the supervision and management of the use of medical security funds to the medical security administrative department as required;
（五）未按照规定向社会公开医药费用、费用结构等信息；
(5) Failure to disclose information such as medical expenses and expense structure to the public as required;
（六）除急诊、抢救等特殊情形外，未经参保人员或者其近亲属、监护人同意提供医疗保障基金支付范围以外的医药服务；
(6) Except for special circumstances such as emergency and rescue, providing medical services outside the scope of medical security fund payment without the consent of the insured person or their close relatives or guardians;
（七）拒绝医疗保障等行政部门监督检查或者提供虚假情况。
(7) Refusing supervision and inspection by the medical security and other administrative departments, or providing false information.
定点医药机构通过下列方式骗取医疗保障基金支出的，由医疗保障行政部门责令退回，处骗取金额2倍以上5倍以下的罚款；责令定点医药机构暂停相关责任部门6个月以上1年以下涉及医疗保障基金使用的医药服务，直至由医疗保障经办机构解除服务协议；有执业资格的，由有关主管部门依法吊销执业资格：
If a designated medical institution defrauds medical security fund expenditures through the following methods, the medical security administrative department shall order the return of the funds, impose a fine of not less than 2 times but not more than 5 times the amount defrauded; order the designated medical institution to suspend the relevant responsible department's medical services involving the use of medical security funds for not less than 6 months but not more than 1 year, until the medical security agency terminates the service agreement; if the institution has a practicing qualification, the relevant competent department shall revoke the practicing qualification according to law:
（一）诱导、协助他人冒名或者虚假就医、购药，提供虚假证明材料，或者串通他人虚开费用单据；
(1) Inducing or assisting others to seek medical treatment or purchase drugs under false names or with false illnesses, providing false certification materials, or colluding with others to fabricate expense documents;
（二）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；
(2) Forging, altering, concealing, tampering with, or destroying medical documents, medical certificates, accounting vouchers, electronic information, and other relevant materials;
（三）虚构医药服务项目；
(3) Fabricating medical service items;
（四）其他骗取医疗保障基金支出的行为。
(4) Other acts of defrauding medical security fund expenditures.
定点医药机构以骗取医疗保障基金为目的，实施了本条例第三十八条规定行为之一，造成医疗保障基金损失的，按照本条规定处理。
If a designated medical institution commits any of the acts specified in Article 38 of this Regulation with the intent to defraud medical security funds, resulting in losses to the medical security fund, it shall be dealt with in accordance with this Article.
个人有下列情形之一的，由医疗保障行政部门责令改正；造成医疗保障基金损失的，责令退回；属于参保人员的，暂停其医疗费用联网结算3个月至12个月：
If an individual falls under any of the following circumstances, the medical security administrative department shall order correction; if losses are caused to the medical security fund, it shall order restitution; if the individual is an insured person, the online settlement of their medical expenses shall be suspended for 3 to 12 months:
（一）将本人的医疗保障凭证交由他人冒名使用；
(1) Allowing others to use their medical security credentials under false pretenses;
（二）重复享受医疗保障待遇；
(2) Duplicating enjoyment of medical security benefits;
（三）利用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。
(3) Taking advantage of the opportunity to enjoy medical security benefits to resell drugs, accept cash refunds, physical goods, or obtain other illegal benefits.
个人以骗取医疗保障基金为目的，实施了前款规定行为之一，造成医疗保障基金损失的；或者使用他人医疗保障凭证冒名就医、购药的；或者通过伪造、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，骗取医疗保障基金支出的，除依照前款规定处理外，还应当由医疗保障行政部门处骗取金额2倍以上5倍以下的罚款。
If an individual, with the intent to defraud medical security funds, commits any of the acts specified in the preceding paragraph, causing losses to the medical security fund; or uses another person's medical security credentials to seek medical treatment or purchase drugs under false pretenses; or defrauds medical security fund expenditures by forging, altering, concealing, tampering with, or destroying medical documents, medical certificates, accounting vouchers, electronic information, and other relevant materials, or by fabricating medical service items, in addition to being dealt with in accordance with the preceding paragraph, the medical security administrative department shall impose a fine of not less than 2 times but not more than 5 times the amount defrauded.
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收受贿赂或者取得其他非法收入的，没收违法所得，对有关责任人员依法给予处分；违反其他法律、行政法规的，由有关主管部门依法处理。
If medical security and other administrative departments, medical security agencies, designated medical institutions, and their staff accept bribes or obtain other illegal income, the illegal gains shall be confiscated, and the responsible persons shall be punished according to law; if other laws or administrative regulations are violated, the relevant competent authorities shall handle the matter according to law.
定点医药机构违反本条例规定，造成医疗保障基金重大损失或者其他严重不良社会影响的，其法定代表人或者主要负责人5年内禁止从事定点医药机构管理活动，由有关部门依法给予处分。
If a designated medical institution violates the provisions of these Regulations, causing significant losses to the medical security fund or other serious adverse social impacts, its legal representative or principal responsible person shall be prohibited from engaging in management activities of designated medical institutions for 5 years, and shall be given sanctions by the relevant departments in accordance with the law.
违反本条例规定，侵占、挪用医疗保障基金的，由医疗保障等行政部门责令追回；有违法所得的，没收违法所得；对直接负责的主管人员和其他直接责任人员依法给予处分。
If anyone violates the provisions of these Regulations by embezzling or misappropriating medical security funds, the medical security and other administrative departments shall order the recovery; if there are illegal gains, the illegal gains shall be confiscated; the directly responsible supervisors and other directly responsible personnel shall be given sanctions in accordance with the law.
退回的基金退回原医疗保障基金财政专户；罚款、没收的违法所得依法上缴国库。
The returned funds shall be returned to the original medical security fund fiscal account; fines and confiscated illegal gains shall be turned over to the state treasury in accordance with the law.
医疗保障等行政部门、医疗保障经办机构、会计师事务所等机构及其工作人员，泄露、篡改、毁损、非法向他人提供个人信息、商业秘密的，对直接负责的主管人员和其他直接责任人员依法给予处分；违反其他法律、行政法规的，由有关主管部门依法处理。
If medical security and other administrative departments, medical security agencies, accounting firms and other institutions and their staff disclose, alter, destroy, or illegally provide personal information or trade secrets to others, the directly responsible supervisors and other directly responsible personnel shall be given sanctions in accordance with the law; if other laws or administrative regulations are violated, the relevant competent departments shall handle the matter in accordance with the law.
医疗保障等行政部门工作人员在医疗保障基金使用监督管理工作中滥用职权、玩忽职守、徇私舞弊的，依法给予处分。
If staff of medical security and other administrative departments abuse their power, neglect their duties, or engage in malpractice for personal gain in the supervision and administration of the use of medical security funds, they shall be given sanctions in accordance with the law.
违反本条例规定，构成违反治安管理行为的，依法给予治安管理处罚；构成犯罪的，依法追究刑事责任。
If a violation of these Regulations constitutes a violation of public security administration, public security administration penalties shall be imposed in accordance with the law; if a crime is constituted, criminal liability shall be investigated in accordance with the law.
违反本条例规定，给有关单位或者个人造成损失的，依法承担赔偿责任。
If a violation of these Regulations causes losses to relevant units or individuals, compensation liability shall be borne in accordance with the law.
附 则
Supplementary Provisions
职工大额医疗费用补助、公务员医疗补助等医疗保障资金使用的监督管理，参照本条例执行。
The supervision and administration of the use of medical security funds such as employee major medical expense subsidies and civil servant medical subsidies shall be implemented with reference to these Regulations.
居民大病保险资金的使用按照国家有关规定执行，医疗保障行政部门应当加强监督。
The use of resident major illness insurance funds shall be carried out in accordance with the relevant provisions of the state, and the medical security administrative department shall strengthen supervision.
本条例自2021年5月1日起施行。
This Regulation shall come into force on May 1, 2021.