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MINISTRY OF
HEALTH
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SOCIALIST REPUBLIC OF VIETNAM
Independence – Freedom – Happiness
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No.: 627/BYT-BH
Re: Guidance on implementation of Article 22 of the Law on Health
Insurance
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Hanoi, January
27, 2021
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To:
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Article 22 of the Law on Health Insurance No.
25/2008/QH12 dated November 14, 2008 as amended in the Law No. 46/2014/QH13
dated June 13, 2014 (hereinafter referred to as “Law on Health Insurance”)
stipulates that, from January 01, 2021, when a health insurance policyholder
receives medical services from any provincial-level hospital of inappropriate
level nationwide, his/her inpatient service costs shall be covered by the
health insurance fund with the same scope and rate of health insurance coverage
as he/she receives medical services from a hospital of appropriate level. After
obtaining the consent from Vietnam Social Security, the Ministry of Health
hereby provides guidance on implementation of the said Article 22 as follows:
1. Reimbursement of costs of
medical services in case a health insurance policyholder receives medical
services from a district-, provincial- or central-level hospital of
inappropriate level and then is requested to use inpatient services:
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b) The health insurance fund shall not reimburse
costs of outpatient services in case the health insurance policyholder has
completed his/her outpatient treatment but then is requested to receive inpatient
treatment or day treatment for the same diagnosis.
2. Reimbursement of costs of
medical services in case a health insurance policyholder receives medical
services from a hospital of inappropriate level and is requested to receive day
treatment:
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b) In case a health insurance policyholder is
requested to use day treatment at a hospital, he/she shall be treated as an
inpatient and shall have his/her day treatment costs reimbursed by the health
insurance fund in the same manner as reimbursement of costs of inpatient
services prescribed herein.
3. Coverage rates and encoding
of data, recording of costs of medical services in case health insurance
policyholders receive medical services from hospitals of inappropriate level as
prescribed in Point c Clause 3, Clause 4 and Clause 6 Article 22 of the Law on
Health Insurance:
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- In case health insurance policyholders use
medical services from district-level hospitals as prescribed in Point c Clause
3 Article 22 of the Law on Health Insurance over the country: They shall have
costs of inpatient and outpatient services reimbursed at the same rates as they
receive medical services from hospitals of appropriate level;
- In case health insurance policyholders use
medical services from provincial-level hospitals as prescribed in Clause 6
Article 22 of the Law on Health Insurance over the country: They shall have
costs of inpatient services reimbursed at the same rates as they receive
medical services from hospitals of appropriate level;
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- Health facilities shall encode data and record
cases of patients who use medical services at hospitals of inappropriate level
as prescribed in Point a Section 1 hereof as follows:
+ Enter code “3” in field No. 16 (MA_LYDO_VVIEN) of
Table 1 enclosed with Decision No. 4210/QD-BYT dated September 20, 2017 of the
Minister of Health prescribing output data standards and formats used in
management, assessment and payment for medical services covered by health
insurance fund;
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+ Select the "Inappropriate level" part
in Section 14 Part I (Administrative works) of the Statement of costs of
medical services enclosed with the Decision No. 6556/QD-BYT dated October 30,
2018 of the Minister of Health promulgating the model statement of costs of
medical services used by health facilities.
+ Enter the coverage rate of 80 or 95 or 100
corresponding to the code of coverage rate specified in the health insurance
card in the “Coverage rate” section in Part II (Costs of medical services) of the
Statement of costs of medical services enclosed with the Decision No.
6556/QD-BYT.
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- He/she shall have costs of
inpatient services reimbursed at the same rates as he/she receives medical
services from a health facility of appropriate level;
- He/she shall be entitled to exemption from
copayment of medical services as prescribed in Point c Clause 1 Article 22 of
the Law on Health Insurance; copayments made by the patient in this case shall
be considered by Vietnam Social Security when issuing certificate of exemption
from copayment in the year.
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+ Enter code “4” in field No. 16 (MA_LYDO_VVIEN) of
Table 1 enclosed with Decision No. 4210/QD-BYT ;
+ Enter the coverage rate of 80 or 95 or 100
corresponding to the code of coverage rate specified in the health insurance
card in field No. 17 (MUC_HUONG) of Table 2 and Table 3 enclosed with Decision
No. 4210/QD-BYT ;
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+ Enter the coverage rate of 80 or 95 or 100
corresponding to the code of coverage rate specified in the health insurance
card in the “Coverage rate” section in Part II (Costs of medical services) of
the Statement of costs of medical services enclosed with the Decision No.
6556/QD-BYT.
c) In case a health insurance policyholder uses
medical services at a hospital of inappropriate level and is receiving
inpatient treatment but his/her health insurance card has been expired:
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- If there is change in the coverage rate specified
in the new health insurance card, the reimbursement of costs incurred from the
effective date of the new health insurance card shall be made according to the
new coverage rate.
- E.g.: A health insurance policyholder holds
a health insurance card whose code is CN3 (coverage rate: 95%), and receives
inpatient services from December 15, 2020; his/her health insurance card of
code CN3 expires on December 31, 2020 and he/she participates in health
insurance for family households and is issued with a new health insurance card
of code GD4 (coverage rate: 80%) which is effective from January 06, 2021;
Until January 20, 2021, he/she is discharged from the hospital. In this case,
costs of medical services shall be reimbursed by the health insurance fund as
follows:
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+ Costs of medical services within the scope of
health insurance coverage incurred from January 01, 2021 to the end of January
05, 2021: the health insurance fund shall make a payment equal to 95% of the
sum of costs (which is the coverage rate of the health insurance card of code
CN3);
+ Costs of medical services within the scope of
health insurance coverage incurred from January 06, 2021 to the end of January
20, 2021: the health insurance fund shall make a payment equal to 80% of the
sum of costs (which is the coverage rate of the health insurance card of code
GD4).
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a) Request heads of units to take charge of and
cooperate with provincial social insurance offices and relevant agencies in:
- Frequently organizing and requesting officials,
public employees and workers under their management to strictly comply with
regulations of laws on medical examination and treatment and health insurance,
Directive No. 10/CT-BYT dated September 09, 2019 and Directive No. 25/CT-BYT
dated December 21, 2020 of the Minister of Health.
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b) On a periodical or ad hoc basis, cooperating
with relevant agencies to organize the inspection of implementation of policies
and laws on health insurance. Heads of health facilities shall assume
responsibility before the law and before the Minister of Health for their
health facilities’ failure to comply with regulations.
5. The Ministry of Health
requests Vietnam Social Security to instruct provincial social insurance
offices to study and cooperate with local relevant units to implement this
Official Dispatch.
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