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SOCIAL SECURITY
ADMINISTRATION OF VIETNAM
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THE SOCIALIST
REPUBLIC OF VIETNAM
Independence - Freedom - Happiness
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No:1399/QD-BHXH
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Hanoi, December
22, 2014
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DECISION
INTRODUCTION
OF REGULATION ON PROVISION AND REIMBURSEMENT FOR COVERED SERVICES
DIRECTOR GENERAL OF SOCIAL SECURITY ADMINISTRATION OF
VIETNAM
Pursuant to the Law No. 25/2008/QH12 on Health Insurance
dated November 14, 2008 and the Law amending and supplementing a number of
Articles of the Law No.46/2014/QH13 dated June 13, 2014;
Pursuant to the Government's Decree
No.105/2014/ND-CP providing details and directives on a number of Articles of the
Law on Health Insurance dated November 15, 2014;
Pursuant to the Government’s Decree
No.05/2014/ND-CP defining functions, responsibilities, entitlement and
organizational structure of Social Security Administration of Vietnam dated
January 17, 2014;
Pursuant to the Joint Circular
No.41/2014/TTLT-BYT-BTC on guidelines for the application of health insurance
dated November 17, 2014;
At request of the Director of the Department of
Health Insurance,
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Article 1. To introduce the regulation on provision of covered services
Article 2. This Decision enters into force from January 01, 2015 and
replaces the Decision No.82/BHXH-QD dated January 20, 2010 and Decision
No.160/BHXH-QD dated February 14, 2011 by Social Security Administration of
Vietnam. Any regulation conflicting with this Decision shall be
annulled.
Article 3. The Chief office of the Social Security Administration of
Vietnam, Directors of Departments of Health Insurance, heads of affiliates to
the Social Security Administration of Vietnam, Directors of North and South
Centers for medical assessing and billing , Directors of Social Security
Administrations of provinces and centrally-affiliated cities(hereinafter
referred to as “province”), Directors of Social Insurances Services affiliated
to the Ministry of National Defense and People’s Public Security of Vietnam
shall be responsible for the implementation of this Decision ./.
DIRECTOR
GENERAL
Nguyen Thi Minh
REGULATION
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Chapter I
GENERAL PROVISIONS
Article 1. Scope
This Regulation stipulates the application of
health insurance to medical examination and treatment in respect of contracts
for provision of covered services, registration for medical facilities,
referral and procedures for provision covered services, coverage and rate of
health insurance reimbursement (hereinafter referred to as “reimbursement
rate”); management, allocation and spending of health funds for covered
services (hereinafter referred to as “health fund”), estimation, funding,
reimbursement and advance of health funds; reporting forms and required
information.
Article 2. Regulated entities
1. The Social Security Administrations of
provinces, Centers for medical assessing and billing , Social Security Services
of Ministry of National Defense and People’s Public Security of Vietnam
(hereinafter referred to as Social Security services of province) and Social
Security Administrations of districts.
2. Medical facilities providing covered services
(hereinafter referred to as “medical facility”).
3. Organizations, agencies, authorities
(hereinafter referred to as “entity”), education institutions under the
national education system (hereinafter referred to as “education
institution") and relevant individuals.
Article 3. Responsibilities
for management and application of health insurance policies
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a) Issue and manage medical facility codes, update
the list of medical facilities and registered medical facilities on the
internal website of the Social Security Administration.
b) Direct the Social Security Administrations of
provinces to estimate examine and assess the annual estimation of reimbursement
for covered services nationwide; allocate and adjust the annual estimation of
the amount of reimbursement for covered services within the province and
inspect the estimation.
c) Determine and allocate health funds and notify
the Social Security Administrations of provinces of 20% of the balance (if any)
for the period of from 01/01/2015 to 31/12/2020 in the annual gross insurance
premium is more than annual amount of reimbursement.
d) Assess the annual reimbursement amount of
provinces.
dd) Manage and regulate health insurance reserve
funds (hereinafter referred to as “reserve fund”).
2. Every Social Security Administration of
Provinces shall
a) Cooperate with the Departments of Health to
- Identify and make the list of medical facilities
qualified for provision of covered services and registered medical facilities
under Regulations of the Ministry of Health;
- Determine types of insured persons, their social
class and the appropriateness of number of enrollees for the capacity and
health fund of registered medical facilities within their province.
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b) Cooperate with Departments of Health and
Department of Finance to: Prepare plans for allocation of 20% of the remaining
health fund and submit them to the People’s Council and People’s Committee of
province for approval.
c) Participate in appraising bidding plans and
preparing invitation to bid, assessing and evaluating bids for provision of
medical equipment, medicines and chemicals under regulations of laws.
d) Direct the Social Security Administrations of
districts to carry out estimation of reimbursement within the district and
self-estimate reimbursement in the province. Allocate and transfer health funds
according to the approved reimbursement estimation to Social Security
Administrations of districts.
dd) Appraise the quarter and annual medical
expenses of the Social Security Administration of province.
e) Sign contracts for allocation of primary
healthcare funds to education institutions.
g) Sign and execute contracts for provision of
covered services with medical facilities of all level within the province;
examine requirements for reimbursement for medical services rendered by
provincial and central level medical facilities that signed contracts with the
Social Security Administration of the district, directly reimburse for eligible
medical expenses prescribed in Article 16 hereof.
h) Manage and allocate the annual health fund as
follows:
- Transfer primary healthcare funds to educational
institutions and entities having medical services qualified for the primary
healthcare fund.
- Transfer health funds to Social Security
Administrations of districts;
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- Reasonably allocate health funds to medical
facilities within the province.
i) Assess the appropriateness of medical services
administered to insured persons, identify reasons for cost overruns on the
health fund (for insured patients referred to by initiating facilities).
k) Centrally manage health insurance database and
medicare coverage database within the province.
l) Aggregate and notify of transfer of intra
provincial and extraprovincial reimbursement.
m) Issue the copayment exemption certificate to the
insured who buys health insurance for at least 05 consecutive years and his/her
copayment is over 06-month statutory base rate ( except for those who
intentionally receive medical care at inappropriate levels).
3. Every Social Security Administration of
districts shall:
a) Estimate and transfer primary healthcare funds
to education institutions and other eligible entities prescribed in Article 18
of the Joint Circular No.41/2014/TTLT-BYT-BTC dated November 24, 2011 by the
Ministry of Health and the Ministry of Finance providing guidance on health
insurance.
b) Sign contracts for provision of covered services
with medical facilities of communes and districts or those at the equivalent
levels as stipulated in Article 1 and 2 of the Circular No. 37/2014/TT-BYT on
guidelines for initial registration and referral within the coverage of health
insurance (except for private hospitals).
c) Directly reimburse for all eligible medical
expenses for insured patients whose application is approved by the Social
Security Administration of the province.
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dd) Issue a copayment exemption certificate to the
insured person who buys health insurance from underwriters appointed by the
social Security Administration of provinces.
e) Every Social Security Administration of district
shall carry out tasks mentioned in point b and d clause 3 of this Article if it
satisfies the following requirements:
- At least 01 specialist specialized in assessment
of the appropriateness of medical services administered to insured patients
obtains 02-year associate degree of medicine or pharmacy or higher;
- There shall be at least 01 accountant in charge
of monitoring the payment and reimbursement of medical expenses.
Chapter II
EXECUTION OF CONTRACTS
FOR PROVISION OF COVERED SERVICES, INITIAL REGISTRATION, REFERRAL AND
PROCEDURES FOR PROVISION OF COVERED SERVICES
Article 4. Contracts for
provision of covered services
1. According to the functions, responsibilities and
capacity of medical facilities, the Social Security Administration shall sign
contracts for provision of covered services as follows:
a) Contracts for provision of outpatient care with
medical facilities providing outpatient services;
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2. Contract award criteria
The Social Security Administration shall sign
contracts for provision of covered services with medical facilities that are
granted medical facility coded by the Social Security Administration of Vietnam
under Article 3 of the Decision No.1314/QD-BHXH on issuance of health insurance
card codes dated December 02, 2014, and meet all requirements stipulated in
Article 42 of the Law on medical examination and treatment, and clause 2,
Article 7 of the Joint Circular No.41/2014/TTLT-BYT-BTC and other relevant
regulations of laws.
3. Assessment prior to contact award
a) For every medical facility that enters into the
first contract for provision of covered services or terminated the last
contract for 06 months or longer
- The department specialized in receiving and
storing documents (hereinafter referred to as “document-receiving department”) of
the Social Security Administration of province or single-window system of
Social Security Administrations of districts (hereinafter referred to as
“single-window system” shall instruct medical facilities to complete their
application for provision of covered services as prescribed in clause 2,
Article 7 of the Joint Circular No.41/2014/TTLT-BYT-BTC and transfer such
application to the department in charge of assessing the appropriateness of
medical services administered to insured patients (hereinafter referred to as
“assessing department”) within the set forth deadline in clause 3, Article 9 on
social security and health insurance administrative procedures issued together
with the Decision No.1366/QD-BHXH dated December 12, 2014 by the Director
General of the Social Security Administration of Vietnam;
- With 07 days from the date of receipt, the
assessing department shall appraise the eligibility for contract award
according to above-mentioned criteria, make out appraisal records using form
02/BHYT enclosed herewith. According to the demand for medical care of insured
persons within the province, number of insured persons and health funds, the
Social Security Administration of the province shall submit an application for
covered service providers’ codes to the Social Security Administration of
Vietnam;
- With 07 days from the date of receipt of the
application and appraisal record made using form 02/BHYT, the Department of
Health Insurance Policy - Social Security Administration of Vietnam shall make
such application and record publicly on their internal website and response to
the applicant in writing.
b) For medical facilities annually signing
contracts for provision of covered services: In case of any adjustments, the
Social Security Administration of province shall request medical facilities
that provide covered services last year to complete their applications for
contracts for provision of covered services under point b, clause 2, Article 7
of the Joint Circular No.41/2014/TTLT-BYT-BTC by December 15th of
every year.
c) Within 30 days from the date of receipt of the
complete application, the Social Security Administration shall consider
awarding the contract for provision of covered services with eligible medical
facility. In case of rejection, the Social Security Administration shall send a
written notice in which reasons for rejection shall be specified.
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a) The Social Security Administration and medical
facility shall conclude the contract using the form in Annex 03 enclosed with
the Joint Circular No.41/2014/TTLT-BYT-BTC, and supplement appropriate terms in
respect of insured patients’ interests and application for assessment of the
appropriateness of medical services administered to insured patients prescribed
in clause 6 of this Article according to the functions, responsibilities and
capacity of the covered service provider.
b) For medical facilities of district or higher;
According to functions, responsibilities and capacity of the medical facility,
additional terms of contracts and methods of reimbursement for eligible medical
expenses shall be included in the contracts for provision of covered services
signed between the Social Security Administration and the medical facility .
c) For maternity wards and health stations of
communes eligible for provision of covered services: The Social Security
Administration of the district and medical facilities or health stations of
district approved by the Department of Health shall negotiate to supplement
additional terms in respect of covered services administered by maternity wards
and health stations of communes to the contract.
d) For general clinics affiliated to hospitals or
health stations of districts: Such general clinic shall conclude a contract for
provision of covered services as a department of the hospital or health station
of the district. Under regulations on qualifications, profession and schedule
of medical services approved by the competent authority, the Social Security
Administration and hospitals or health stations of province shall supplement
terms in respect of covered services to the contract.
dd) For healthcare services of education
institutions and entities (hereinafter referred to as “organizational health
service”) other than those funded with primary healthcare funds, the Social
Security Administration shall directly sign the contract with such education
institution or entity in charge of management of organizational health
services. In case of under-provision of medicines, chemicals or medical
equipment or services, the Social Security Administration shall sign the
contract with hospital or health stations of the district.
5. Contract validity
a) For medical facilities that enter into the first
contract for provision of covered services or terminated their last contract
for 06 months or longer The contract shall come into effect from the date of
signature up to December 31 of the signing year inclusive.
b) For medical facilities annually entering into
contracts for provision of covered services: The Social Security Administration
and medical facility shall sign the contract by December 31 of the immediately
preceding year. The contract shall come into effect from January 01st
to December 31 of that year inclusive.
6. Documents required for assessment of the
appropriateness of medical services administered to insured patients.
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b) A schedule of medical service prices approved by
the competent authority.
c) A schedule of medical services prices decided by
the medical facility
d) A list of medicines, chemicals and medical
equipment for covered services by bidding result or a list of those legally
procured in other form or shape; a list of self-prepared medicines and their
proposed prices (if any).
dd) Proposals and agreements on cooperation in
medical services, employment contracts between the medical facility and
practitioners (if any); Decision on technical transfer to lower levels or
Decision on medical assistance issued by the competent authority.
e) Lists of reimbursed medical expenses.
g) Other documents related to covered services and
reimbursement under clause 2, Article 43 of the Law amending the Law on Health
Insurance.
Physical and electronic documents and information
for assessment of the appropriateness of covered services administered to
insured patients.
7. Contract execution
a) For medical facilities
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- Welcome insured patients and
inspect the procedures for covered services provided for insured patients;
- Administer medical services
as agreed in the contract for provision of covered services, in case of lack of
medicines, chemicals or medical equipment, the medical facility shall reimburse
for cost of such medicines, chemical and materials that insured patients buy
outside, and submit request for payment to the Social Security Administration
under regulation of laws.
- Provide documents required
for assessment of the appropriateness of medical services administered to
insured patients under clause 6 of this Article; provide insured patients with
medical bills which specify copayments and self-payments;
- Promptly notify the Social
Security Administration of changes related to the provision of medical services,
medicines, medical equipments and substances, and functions and
responsibilities of the medical facility in writing.
- Monthly and quarterly submit
a list of insured patients using the forms C79a-HD and C80a-HD enclosed with
the Circular No.178/2012/TT-BTC dated October 23, 2012 by the Ministry of
Finance providing guidance on accounting for social security (make out a list
of organ donors without health insurance under treatment after organ donation
and list of uninsured patients under the age of 06 enclosed with the copy of
their birth certificate or report of birth );
- Effectively manage and use
health funds in accordance with regulations of laws. In case of overruns, the
medical facility shall submit an explanation to the Social Security Administration
within 30 days from the date on which the reimbursement record is signed.
b) For Social Security Administration
Every Social Security Administration shall:
- Cooperate with medical
facilities to inspect the procedure for administration of covered services;
disseminate health insurance policies and regulations, and deal with issues in
relation to insured patient benefits;
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- Promptly notify medical
facilities of changes in health insurance codes and estimated funds in writing.
- Examine and respond in
writing to the reimbursement in relation to changes in medicines, medical
equipment and chemicals, and functions and responsibilities of the Department
of Health.
- Quarterly assess the cost
overruns and make up deficits under regulations of laws;
- Cooperate with medical
facilities to determine the actual average expense by the coverage of an
outpatient and inpatient treatment series or by specialty of referrals in the
preceding year as the basis for determination of the
maximum reimbursement for the receiving facility under clause 6, d 11 of the
Joint Circular No.41/2014/TTLT-BYT-BTC.
8. Contract document and
report management and retention
a) The assessing department shall retain all
contract documents and the Department of Finance and Planning shall keep 01
copy of the contract.
b) The Social Security Administration of the
province shall submit a report on contracts for provision of covered services
using the form 13/BHYT enclosed herewith to the Social Security Administration
of Vietnam by January 15th of every year; and report to the Social Security
Administration of Vietnam in case any new medical facility enters into the
contract or the medical facility adjust their operation, level or medical
services.
Article 5. Registration for
medical facilities for covered services
1. The medical facility is
entitled to provide covered services if it satisfies requirements stipulated in
clause 2, Article 4 hereof and Article 5 of the Circular No.37/2014/TT-BYT.
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a) Insured persons are entitled to register medical
facilities to receive covered services as stipulated in Articles 6 and 7 of the
Circular No.37/2014/TT-BYT.
b) Every insured person shall be entitled to
register another medical facility at the beginning of every quarter.
3. Procedures for registration
a) The assessing department shall transfer the list
of medical facilities qualified for being registered medical facilities in the
province to the department of health insurance cards and books, and department
of informatics; and submit the list of registered medical facilities providing
covered services for insured patients not residing in the province to the
Social Security Administration of Vietnam.
b) The document-receiving department shall notify
the list of medical facilities qualified for being registered medical
facilities to insured person and instruct them to select or change their registered
medical facility under clause 2 of this Article.
Article 6. Referral
1. The referral of insured
patients shall be made in accordance with Articles 5, 6 and 7 of the Circular
No.14/2014/TT-BYT dated April 14, 2014 on referral between medical facilities
and Articles 8 and 9 of the Circular No.37/2014/TT-BYT.
The initiating facility shall fill the referral
from using the Annex 01 enclosed with the Circular No.14/2014/TT-BYT. In case
of referral at request of the insured patient, the initiating facility shall
follow clause 5, Article 5 of the Circular No.14/2014/TT-BYT.
2. In case of referral
prescribed in point b, clause 2, Article 9 of the Circular No.37/2014/TT-BYT,
the initiating facility shall comply with point a, clause 1, Article 5 of the
Circular No.14/2014/TT-BYT for the insured patient interests.
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1. The procedure for access to
covered services shall be conformable to Article 8 of the Joint Circular
No.41/2014/TTLT-BYT-BTC.
- In case of absence of photo
on the health insurance card, insured patients may present other equivalent
identification documents such as ID card, passport, membership card of
Vietnam’s Communist Party, Military ID card, student card, veteran ID card,
driving license or other legal documents enclosed with photos;
- In case of reissue or
replacement of health insurance cards, patients shall present a document
receipt and follow-up appointment for test result return using the form 01/PH
issued together with the Decision No.1366/QD-BHXH. Such appointment shall
specify the insured’s information and shall expire after 07 days from the date
of issue. The follow-up appointment shall be signed and sealed by the Director
of Social Security Administration of districts;
- Any patient who had donated
their organ but have not had a health insurance card shall present their
hospital discharge form prescribed in point a, clause 2, Article 5 of the Joint
Circular No.41/2014/TTLT-BYT-BTC.
2. In case of referral,
insured patients shall present the referral from using the Annex 01 enclosed
with the Circular No.14/2014/TT-BYT.
3. Insured patients shall also
present the copayment exemption certificate made using form 05/BHYT enclosed
herewith to be exempted from copayments is they receive medical care at
appropriate level.
Chapter III
HEALTH INSURANCE
COVERAGE
Article 8. Health insurance
coverage
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1. Medical examination fees at
the price approved by the competent authority.
2. Costs for hospital stays at
the price approved by the competent authority if :
a) The insured inpatient is referred from the
district medical facility.
b) Insured Inpatients do not stay for more than 03
days at medical stations of communes at the cost approved by the competent
authority. For medical stations of disadvantaged communes or islands, insured
patients shall not stay for longer than 5 days.
3. Medical expenses at the
price approved by the competent authority.
For medical services which are administered by
medical staff of superior medical facilities in rotation or under medical
professional assistance programs stipulated in regulations of the Ministry of
Health but have not priced yet, the expenses shall be covered at the price
applied by the superior medical facility that conducts the technology transfer.
4. Costs of medicines, medical
equipment and chemicals directly applied to patients by the list at the
reimbursement rate and under terms of payment prescribed by the Minister of
Health but not included in medical service costs.
5. Costs of blood and blood
products prescribed in the Circular No.33/2014/TT-BYT on the ceiling price of
standard blood bags and whole blood dated October 27, 2014 by the Ministry of
Health.
6. Costs of transport of
patients from district medical facilities to the higher level in case of
emergency or referral of inpatients prescribed in points d, e, g, h and i,
clause 3, Article 12 of the Law on amendments to the Law on Health Insurance.
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1. Insured patients prescribed
in Articles 26, 27 and 28 of the Law on Health Insurance and clauses 4 and 5,
Article 22 of the law on amendments to the law on health insurance shall have
their medical expenses covered at the following rate:
a) 100% of medical expenses within the coverage of
health insurance (do not apply the reimbursement rate decided by the Ministry
of Health to some medicines, chemicals, medical equipment and services ), and
costs of transport at the reimbursement rate stated in the health insurance
card coded No. 1 under the Decision No.1314/QD-BHXH.
b) 100% of medical expenses within the coverage of
health insurance (the reimbursement rate of some medicines, chemicals, medical
equipment and services is decided by the Minister of Health), and costs of
transport at the reimbursement rate stated in the health insurance card coded
No. 2 under the Decision No.1314/QD-BHXH.
c) 100% of medical expenses within the coverage of
health insurance ( the reimbursement rate of some medicines, chemicals, medical
equipment and services is decided by the Minister of Health) if the treatment
costs less than 15% of the statutory pay rate or medical examination and
treatment is administered by medical facilities of communes.
d) 100% of medical expenses within the coverage of
health insurance (the reimbursement rate of some medicines, chemicals, medical
equipment and services is decided by the Minister of Health) if the insured
patient has been buying health insurance for at least 05 consecutive years and
his/her amount of annual copayment is more than 06-month statutory pay rate
altogether. Insured patients shall retain all receipt of copayment in order to
be granted the copayment exemption certificate.
dd) 95% of medical expenses within the coverage of
health insurance (the reimbursement rate of some medicines, chemicals, medical
equipment and services is decided by the Minister of Health), costs of
transport at the rate of health insurance reimbursement prescribed in the
health insurance card coded by No. 3 under the Decision No.1314/QD-BHXH.
e) 80% of medical expenses within the coverage of
health insurance (the reimbursement rate of some medicines, chemicals, medical
equipment and services decided by the Minister of Health), and costs of
transport at the reimbursement rate stated in the health insurance card coded
No. 4 under the Decision No.1314/QD-BHXH.
g) 100% of medical expenses including expenses
beyond the coverage of health insurance and cost of transport at reimbursement
rate prescribed in the health insurance card coded No. 5 under the Decision
No.1314/QD-BHXH.
2. Insured patients receiving
medical care at medical facilities other than their registered facility without
referral form (except for emergencies and cases stipulated in point a, d, c,
dd, and e, clause 5 of this Article shall promptly present their health
insurance card to be reimbursed for medical expenses under Article 8 and clause
1 of Article 9 at the reimbursement rate as follows :
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b) At provincial hospitals: 60% of the medical
expenses for inpatients receiving medical care from 01/01/2015 to 31/12/2020;
100% of the medical expenses for inpatients receiving medical care from January
01, 2021 onwards;
c) At district hospitals specified in clauses 1, 2,
3, 9 and 10 of the Circular No.37/2014/TT-BYT, and district health stations
that are not separated from district hospitals (including general clinics
affiliated to such medical facilities): 70% of the medical expenses for
inpatients receiving medical care from 01/01/2015 to 31/12/2015; or 100% of the
medical expenses for inpatients receiving medical care from January 01, 2016
onwards.
3. If insured patients select
their caregiver and medical room, the medical expenses shall be reimbursed
within the coverage of health insurance at the reimbursement rate prescribed in
clause 1 or 2 of this Article.
4. The amount of medical
expenses beyond the coverage of health insurance prescribed in Article 8 or
reimbursement rate clause 1 of this Article and medical expenses for
outpatients prescribed in points a and b , clause 2 and 3 of Article 9 hereof
shall be paid by the insured patient.
5. The reimbursement rate is
specified as follows:
a) From January 01, 2016 onwards, insured persons
registering for medical examination and treatment at health stations of
communes or general clinics or district hospitals are entitle to receive
medical care administered by other health station of communes, general clinics
or district hospitals within the province and shall have medical expenses
covered at the reimbursement rate prescribed in clause 1 of this Article.
b) Insured patients holding insurance cards on
which the residential address is coded as K1, K2 or K3 and receiving medical
care at inappropriate level shall have their medical expenses covered at the
district /provincial/central hospital at the reimbursement rate prescribed in
point b, clause 1 of this Article.
c) From January 01, 2021 onwards, any insured patient
picks one of inappropriate level facilities of district shall have their
medical expense covered at the reimbursement rate prescribed in clause 1 of
this Article.
d) Post-emergency patients referred to other
department or medical rooms or hospitals shall have their medical expense
covered at the reimbursement rate prescribed in clause 1 of this Article.
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e) In case of referral, the insured patients
getting their disease not mentioned in the referral form cured shall have
medical expenses covered at the reimbursement rate prescribed in clause 1 of
this Article. This provision shall not apply to follow-up examination or
treatment if the insured patient repeatedly use the referral form made within a
fiscal year as stipulated in point d, clause 2, Article 9 of the Circular
No.37/2014/TT-BYT.
g) Insured patients requiring medical care on
days-off or holidays stipulated in clause 5, Article 13 of the Joint Circular
No.41/2014/TTLT-BYT-BTC shall have their medical expenses covered at the
reimbursement rate prescribed in clause 1 of this Article. Such insured
patients shall pay medical expenses beyond the coverage and reimbursement rate
of health insurance (if any).
h) Insured patients receiving medical care at
non-public medical facilities shall have their medical expenses covered but not
exceeding the reimbursement of the same level public medical facilities.
i) Insured patients receiving medical care at
public medical facilities which provide medical services for profit shall have
their medical expense covered under regulations of laws but not exceeding the
reimbursement approved by the competent authority.
k) Costs of patient transport shall be reimbursed
as stipulated in clause 1, Article 13 of the Joint Circular
No.41/2014/TTLT-BYT-BTC.
Chapter IV
MANAGEMENT, ALLOCATION
AND SPENDING OF HEALTH FUNDS
Article 10. Management,
allocation and spending of health funds
1. Health funds
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b) The social Security of Vietnam shall manage
health funds and promptly and sufficiently transfer to the Social Security
Administrations of provinces. Health fund shall be allocated to:
- Medical expenses within the
coverage under the Law on health insurance and other guidance;
- Primary healthcare funds to
education institutions and medical facilities that are eligible for funding for
primitive healthcare under Article 18 of the Joint Circular
No.41/2014/TTLT-BYT-BTC.
2. Reserve funds for covered
services
a) The reserve fund is constituted from:
- The remaining of 10% of the
total annual premium after allocation to the administrative expense but not
less than 5%.
- Earnings from investment of
temporary idle premium funds;
- 80% of the remaining health
funds for the period of from 01/01/2015 to 31/12/2020 ; or 100% of the
health funds since 01/01/2021 onwards;
- Premium outstanding debts of
previous years collected;
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- Reimbursements that were
finalized in the immediately preceding year returned to the health insurance
fund under the decision of the competent authority.
b)Reserve funds shall be centrally managed by the
Social Security Administration of Vietnam and shall be used for raising health
i funds of social Security Administrations of provinces where the total premium
is less than the total reimbursement.
c) The remaining reserve fund shall be included in
the next year reserve fund under point b of this clause.
Article 11. Estimation and
transfer of primary healthcare funds
1. The document-receiving
department shall instruct education institutions and entities to submit the
application for primary healthcare funding using form 01/BHYT enclosed herewith
to the Social Security Administration by October 31 of every year.
2. Single-window department
shall receive such applications and transfer them to the document-receiving
department.
3. Document-receiving
department shall process such applications as follows:
- For education institutions:
Within 02 working days, according to the number of students buying health
insurance, the education institution shall submit a list of students applying
for health insurance using the form D03-TS issued together with the Decision
No.1111/QD-BHXH dated October 25, 2011 by the Director General of Social
Security Administration of Vietnam, a list of students holding health insurance
by special group using form 03/BHYT enclosed herewith, list of
under-06-year-old children (including all children under the age of 06 within
the locals or children being relatives of those prescribed in point a, clause
3, d 12 of the Law on amendment to the Law on health Insurance) to the
Department of Finance and Planning (or Accounting department).
- For relevant entities: The
document-receiving department shall monthly calculate the premiums of their
workers and submit the premium calculation sheet to the Department of Finance
and Planning (or Accounting department).
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a) Take charge of awarding contracts and
transferring primary healthcare funds to education institutions using form
C84a-HD enclosed with the Circular No.178/2012/TT-BTC by the first month of the
academic year or course; and adjust the primary healthcare fund according to
the actual premiums and finalize the contract using form C84b-HD enclosed with
the Circular No.178/2012/TT-BTC at the end of the fiscal year.
b) Monthly transfer the primary healthcare fund to
the unit that paid for their workers’ premiums
c) Include the primary healthcare fund in the
annual reimbursement of the province.
5. The assessing department
shall periodically or surprisingly inspect the allocation of primary healthcare
fund by education institutions and entities under Article 18 of the Joint
Circular No.41/2014/TTLT-BYT-BTC.
Article 12.Health funds at
Social Security Administration of provinces
1. The health fund at the
Social Security Administration of the province is raised from the
remaining budget of 90% of annual premium prescribe in clause 1, Article 6 of
the Decree No.105/2014/ND-CP.
2. The health fund is
allocated for:
a) Primary healthcare stipulated in clause 2,
Article 17 of the Joint Circular No.41/2014/TTLT-BYT-BTC.
b) Referral under Article 14 hereof
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- 55% of health funds of
medical facilities signed contracts for provision of covered services for
outpatients; 10% of health funds of medical facilities signed contracts for
provision of covered services for outpatients and inpatients
- The remaining health fund
after transferring to the medical facility similar to health stations of
communes;
- The remaining health fund
after transferring fixed amount to medical facilities requiring payment by
capitation;
- The remaining capitation
fund after deduction from the amount of transfer to medical facilities under
point b, clause 1, Article 10 of the Joint Circular No.41/2014/TTLT-BYT-BTC;
and the remaining health fund of medical facilities requiring fee-for-service
payment (if any);
- 90% of premiums paid by
holders of health insurance cards which are issued or registered at other
provinces.
Article 13. Management and
allocation of health funds directly managed by the Social Security
Administrations of provinces
Health fund specified in point c, clause 2; Article
12 hereof is used for reimbursing for:
1. Medical expenses for
inpatient care at registered medical facilities signed contracts for provision
of outpatient care.
2. Medical expenses for
medical care at medical facilities other than registered facilities.
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4. Medical expenses of insured
patients whose registered medical facility is located at a
different province.
5. Previous year medical
expenses of fee-for service medical facilities which are permitted to be
finalized in this fiscal year.
6. Health funds of medical
facilities where come in over budget due to force majeure events or objective
causes.
Article 14. Health funds of
medical facilities
1. Determination of health
fund for registered medical facilities
The health fund for registered medical facilities
shall be determined according to the contract for provision of covered
services. To be specific:
a) For fee-for service medical facilities:
Amount of health
fund for registered medical facilities
=
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-
total primary
healthcare fund of the province
x
Number of health
insurance holders registering the medical facility
Number of health
insurance per annum
- The total health fund of the
province is determined under clause 1, Article 12 hereof;
- Total primary healthcare
fund of the province is determined under clause 2 of Article 17 of the Joint
Circular No.41/2014/TTLT-BYT-BTC;
- Number of health insurance
cards per year shall be equal to the total number of health insurance cards
which are valid counted as at the end of every month divided by 12;
- Number of health insurance
holders registering the medical facility are exclusive of health insurance
holders whose cards are issued by Social Security Administration of other
provinces. For medical facilities designated to administer medical examination
and treatment at health stations of communes, the number of health insurance
holder registering the medical facility are inclusive of those registering
health stations of communes;
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- For registered medical
facilities executing contracts for covered outpatient and inpatient services,
the health fund shall account for 90% of health funds of other medical
facilities;
b) The health fund for registered fee-for-service
medical facilities shall be quarterly determined as follows:
- By the fifth of the
beginning of every quarter, the document-receiving department shall take charge
of and cooperate with the Department of Health Insurance Cards and Books shall
calculate the average number of cards in the previous quarter ; the number of cards
firstly registered for every medical facility within the province and the
amount of premiums of previous quarter using form B05-TS issued together with
the Decision No.1111/QD-BHXH and report to the Department of Finance and
Planning and assessment department. The average number of cards in the previous
quarter equals (=) total of health insurance cards counted at the end of the
previous quarter divided by (:) 03;
- According to the aforesaid
form B05-TS, the Department of Finance and Planning shall take charge of and
cooperate with the assessing department to determine the health fund (after
deduction from primary healthcare funds) and send the medical facility a
notification of health fund and medical expenses using the form C81-HD issued
together with the Circular No.178/2012/TT-BTC within 30 days from the date of
receipt of quarter financial statement from the medical facility.
- The Department of Finance
and Planning shall adjust the health fund and notify the medical facility of
adjustment (if any) in the fourth quarter of every year. The annual health fund
shall be the sum of quarter health funds altogether.
c) For medical facilities applying capitation
system:
- The capitation fund is
determined under clauses 2 and 3, Article 10 of the Joint Circular
No.41/2014/TTLT-BYT-BTC;
- Capitation rate is
determined on the basis of inpatient and outpatient medical expenses which has
been finalized.
- The assessing department
shall cooperate with the Department of Finance and Planning to regulate
capitation fund for the medical facility by the year ended on the basis of
adjustment coefficient and expenditures incurring beyond the designated budget.
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2. Management and allocation
of health fund by registered medical facilities
a)The health fund of registered medical facilities
shall be used for reimbursing for covered service expenses including those
which will be directly reimbursed by the Social Security Administration and
costs of transport (if any).
b) The registered medical facility shall be
entitled to manage and allocate the capitation fund for provision of covered
services for insured patients in accordance with clause 4, Article 10 of the
Joint Circular No.41/2014/TTLT-BYT-BTC.
c) Any covered service expense of the previous year
which is reimburse in the current year by the Social Security Administration of
Vietnam shall be included in the capital fund of the current year.
3. Funding for covered
services at health stations of communes or organizational healthcare services
a) Covered services at health stations shall be
funded with the health fund of the medical facility designated to administer
covered services at health stations of communes within their administration
under point a, clause 4, Article 7 of the Joint Circular No.41/2014/TTLT-BYT-BTC.
b) The funding for covered services administered at
organizational healthcare departments which are similar to health stations of
communes shall occupy at least 10% of the covered outpatient care fund but
shall not exceed 20% of the covered outpatient care calculated by number of
registering holders. Such funding shall be used for reimbursing for expenses of
covered services administered to their staff receiving medical care at the
organizational healthcare department .
Chapter V
ADVANCE, SETTLEMENT AND
FINALIZATION OF HEALTH FUNDS
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1. Advance of health funds
a) After receipt of the financial statement (using
form 79a-HD or 80a-HD) of the previous quarter of the medical facility, the
assessing department shall submit a request for advance using form 12/BHYT
enclosed herewith to the Department of Finance and Planning (or accounting
department).
Within 05 working days from the date of receipt of
the request, the Department of Finance and Planning (or accounting department)
shall make a lump-sum advance of 80% of the medical expenses stated in the
previous quarter financial statement.
b) Procedures for advance
- By the fifth of the first
month of every quarter, the Department of Finance and Accounting shall give an
advance of at least 80% of the medical expenses stated in the previous quarter
financial statement to the Social Security Administration of the province.
- By the 17th of
the first month of every quarter, the Department of Finance and Planning shall
submit an aggregate report on advance requests by medical facilities within the
province using form12/BHYT to the Social Security Administration of Vietnam;
- Within 02 working days from
the date of receipt, the Department of Finance and Accounting shall arrange to
give an advance of 80% of the medical expenses stated in the previous quarter
financial statement to the Social Security Administration of the province.
2. Transfer of health funds
a) By 15th of the second months of every
quarter, the Department of Finance and Planning shall take charge of and
cooperate with the assessing department to determined health fund and submit
the quarter medical expense statement using the form 15/BHYT enclosed herewith
to the Social security Administration of Vietnam.
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c) Within 05 working days from the date of receipt,
the Social Security Administration of Vietnams shall settle sufficient
reimbursements to medical facilities and report to the Department of Finance
and Accounting - Social Security Administration of province in writing.
3. Settlement and finalization
of health funds to medical facilities
Under terms of contracts for provision of covered
services, documents and medical bills specified by the Ministry of Finance, the
Social Security Administration shall finalize and reimburse all medical
expenses for covered services to medical facilities under point a, b and c,
clause 2, Article 32 of the Law on amendments to the Law on Health Insurance.
To be specific:
a) Every medical facility shall monthly submit a
electronic and physical list of insured patients requesting to receive
reimbursement in the previous month (using form C79a-HD and C80a-HD issued
together with the Circular No.178/2012/TT-BTC); list of medical equipment which
are quarterly funded with health insurance fund and applied to insured
inpatients and outpatients using form 19/BHYT, list of medicines quarterly
administered to insured outpatients and inpatients using form 20/BHYT and list
of medical services administered to insured inpatients and outpatients using
form 21/BHYT issued together with this Decision to the assessing department for
determination of medical expense reimbursement.
b) Quarterly, the assessing department shall:
- Make out a list of insured
patients approved to be reimbursed using form C79b-HD and C80b-HD issued
together with the Circular No.178/2012/TT-BTC; and transfer the list of
uninsured under-06-year-old patients enclosed with their report of birth or
certificate of birth, lists of uninsured organ donors receiving treatment after
transplantation to the department of health insurance cards –books for issue of
health insurance cards as stipulated in point b, clause 2 or point b, clause 3,
Article 13 of the Joint Circular No.41/2014/TTLT-BYT-BTC.
- Balance and allocate quarter
health funds for reimbursement for medical expenses to intra and
extraprovincial medical facilities to reimburse for medical expenses incurring
in the previous quarter to registered medical facilities ;
- By 15th of the
second month of every quarter, submit all documents made using forms 14/BHYT,
19/BHYT, 20/BHYT and 21/BHYT, physically and electronically, to the Department
of Health Insurance Policy – Social Security Administration of Vietnam; and
those made using forms19/BHYT, 20/BHYT and 21/BHYT , physically and
electronically, to the Department of Pharmacy and medical equipment-Social
Security Administration of Vietnam.
c) The Department of Finance and Planning (or
accounting department) shall quarterly take charge of and cooperate with the
assessing department to:
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- Notify the assessment
results to the medical facility using forms C79b-HD, C80b-HD, C81-HD or C82-HD
issued together with the Circular No.178/2012/TT-BTC within 30 days from the
date of receipt of the financial statement of the medical facility;
- With the 10 following days,
sign the reimbursement record using form C82-HD issued together with the Circular
No.178/2012/TT-BTC and completely settle reimbursement to medical facilities
4. Settlement and finalization
of medical expenses to medical facilities which came in over budget
a) For medical facilities that go over budget: within
20 days from date of receipt of the explanation, the assessing department shall
take charge of and cooperate with the department of Finance and Planning and
relevant departments to assess and identify causes of cost overruns. Any cost
overrun on health funds due to objective causes or force majeure events shall
be included in the next quarter balance sheet. Overruns on capitation fund due
to objectives causes or force majeure events shall be reimbursed at least 60%.
b) Any medical facility that provides outpatient
and inpatient care having a deficit shall quarterly be made up with 10% of the
remaining health fund; and those providing only outpatient care shall be funded
with up to 5% of the remaining healthcare; In case deficits still exist after being
made up, the Social Security Administration of province shall make up such
deficit with the health fund of the province. In the event that the health fund
of the province is not sufficient to make up such deficit, the Social Security
Administration of province shall submit a report on cost overrun assessment to
the social security Administration of Vietnam.
c) Any Social security Administration of province
faces deficits shall submit a report on cost overrun assessment to the social
security Administration of Vietnam by April 30 of the following year.
d) By August 30 of every year, the Department of
Health Insurance Policy shall take charge of and cooperate with relevant
agencies to inspect and assess causes of cost overruns according to the report
submitted by the Social Security Administration of the province, and request
the Director General of the Social Security Administration of Vietnam to
consider approving for using the reserve fund for making up for the deficit.
dd) Within 03 working days from the date of receipt
of the approval, the Department of Finance and Accounting shall transfer money
to the Social Security Administration of the by the Social Security
Administration of Vietnam and shall be used for raising health insurance funds
of social Security Administrations of province.
e) Within 05 working days from the date of receipt,
the Social Security Administration of the province shall reimburse for medical
facilities and report to the Department of Finance and Accounting - Social
Security Administration of province in writing.
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1. Cases eligible for direct
reimbursement
The Social security Administration shall directly
reimburse for medical expenses for insured patients prescribed in Article 14 of
the Joint Circular No.41/2014/TTLT-BYT-BTC.
2. Applications for direct
reimbursement
The application for direct reimbursement shall be
conformable to Article 15 of the Joint Circular No.41/2014/TTLT-BYT-BTC; or
enclosed with the power of attorney or certificate of legal representative if
the applicant is patient’s guardian.
3. Direct reimbursement rate
The direct reimbursement rate shall be conformable
to clause 3, Article 16 of the Joint Circular No.41/2014/TTLT-BYT-BTC. To be
specific:
a) Insured patients receiving emergency care at
medical facilities not signing contracts for provision of covered services
shall have their actual medical expense covered within the coverage of the
health insurance prescribed Article 8 at the reimbursement rate prescribed in
clause 2, Article 9 hereof.
b) Insured patients receiving medical care other
than emergency at medical facilities not signing contracts for provision of
covered services shall have their actual medical expense covered within the
coverage of the health insurance prescribed Article 8 at the reimbursement rate
prescribed in clause 2, Article 9 hereof but not exceeding the reimbursement
rate prescribed in the Article 4 enclosed with the Joint Circular
No.41/2014/TTLT-BYT-BTC.
c) Insured patients receiving medical care at medical
facilities which enter into contracts for provision of covered services but not
presenting all required documents shall have their medical expense covered
within the coverage stipulated in Article 8 at the reimbursement prescribed in
clause 2, Article 9 hereof.
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Single-window department shall:
- Receive and examine
applications for direct reimbursement transfer and instructed insured patients
to provided complete application under clause 2 of this Article and copy all
documents specified in clause 9, Article 8 of the Joint Circular
No.41/2014/TTLT-BYT-BTC, collate with the originals and countersign such copies
and issue an appointment form to the applicants
- Transfer applications for
direct reimbursement to the accessioning department within the same working
day.
b) The assessing department shall
- Make out the written request
for assessment using form 07/BHYT enclosed herewith within 02 working days in
case insured patients receive medical care at facilities out of the province.
- Complete the assessment and
send the applicant for request a notification of assessment results and medical
expense schedule issued under the Decision No.3455/QD-BYT dated September 16,
2013 by the Minister of Health within 25 days;
- Within 03 days from the date
of receipt of the assessment results, the assessing department shall submit a
list of medical expenses directly covered using form C78-HD issued together
with the Circular No.178/2012/TT-BTC to the Department of Finance and Planning.
c) The Department of Finance and Planning (or
Accounting Department) shall:
- Examine the validity of
medical bills, documents and applications for direct reimbursement and transfer
them to the single-window department within 02 days from the date of receipt of
the list of medical expensed directly covered.
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5. The Social Security
Administration shall receive application for direct reimbursement for covered
services in the fiscal year up to the end of the first quarter of the following
year. In case of under-provision of medicines, and medical equipment, the
medical facility shall reimburse for medicines and medical equipment which
insured patient purchased outside, and report to the Social Security
Administration for payback thereafter. The Social Security Administration of
provinces shall make this Regulation publicly to insured persons.
Article 17. Transfer of
reimbursements
1. Principles:
a) Intra-provincial reimbursement herein refers to
the transfer of reimbursement for medical expenses of insured patients
receiving medical care at medical facilities other than their registered
medical facility within the province where their health insurance card is
issued.
b) Extra-provincial reimbursement herein refers to
the transfer of reimbursement for medical expenses of insured patients
receiving medical care at medical facilities in provinces other than the
province where their health insurance card is issued.
c) Transfer of reimbursement for primary healthcare
expenses refers to the transfer of reimbursement if insured students receiving
medical care at medical facilities in provinces other than the province where
their health insurance card is issued.
2. Transfer of reimbursement
to receiving facilities
a) Receiving medical facilities prescribed in
points a and b, clause 1 of this Article shall be have their covered service
expenses reimbursed. The maximum reimbursement shall be determined in
accordance with clause 6, Article 11 of the Joint Circular
No.41/2014/TTLT-BYT-BTC.
For medical facilities entering into contracts for
provision of covered services for the first time, the maximum reimbursement
shall be determined according the average medical expenses of the previous year
by specialty administered by in-network medical facilities.
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In case of cost overruns, the assessing department
shall take charge of and cooperate with relevant departments to indentify
causes of overruns within 30 days from the date of receipt of the explanation
of the receiving medical facility. The cost overruns (if any) shall be included
reimbursed on the next quarter.
The Social Security Administration shall balance
the reimbursement between quarters in the year and adjust reimbursement for
out-of-pocket expenses. Out-of-pocket expenses shall not be reimbursed.
3. Notification of
intra-provincial reimbursement
a) Within 25 days from the date of receipt of
physical and electronic documents made using for C79a-HD and C80a-HD issued
together with the Circular No.178/2012/TT-BTC, the Social Security
Administration of district shall assess and transfer them to the assessing
department to calculate inpatient and outpatient care expenses of medical
facilities using form 14/BHYT issued together with this Decision.
b) Within 05 days from the date of receipt of data
and report of the Social Security Administration of district, the assessing
department shall compare medical data to health insurance data of the whole
province; refuse to reimburse or request to carry out re-assessment in the
absence of information or where information is incorrect. The assessing
department shall notify of reimbursement transfer to the Social Security
Administration of the district.
4. Notification of
extraprovincial reimbursement transfer
a) By 15th of the second month of every
quarter, the Social Security Administration of provinces shall submit both
electronic and physical integrated sheet of extra province reimbursement using
form No.11/BHYT issued together with this decision to the North Center for
medical assessing and billing - Social Security Administration of Vietnam.
b) by 30th of the second month of every
quarter, the North Center for medical assessing and billing shall assess and
notify of reimbursement transfer to the Social Security Administration of
provinces using form C88-HD issued together with the Circular
No.178/2012/TT-BYT, physically and electronically. The North Center for medical
assessing and billing may refuse to make payment in case the information
provided in request for reimbursement transfer is incorrect or incomplete.
c) After receipt of reimbursement transfer
notification, the Social Security Administration of the province where the
health insurance card is issued shall compare information of the insured
patient who received medical care at medical facilities out of the province
with medical data in the province and health insurance data. The Social
Security Administration of the province may request a re-assessment in case the
health insurance card is not available in the health insurance or referral
data, or the date of treatment is treasonable; and allocate funding for
extra-provincial indirect reimbursement that shall be deducted from health fund
of registered medical facilities.
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a) Within 15 days from the date of receipt of
reimbursement transfer notification, the Social Security Administration where
the health insurance card is issued shall double-check reimbursement data and
submit a request for re-assessment (where necessary) to the North Center for
medical assessing and billing.
b) Within 30 days from the date of receipt of the
request for re-assessment, the Social Security Administration of the province
where the insured patient came for medical care shall reply in writing.
In case the medical facility where the medical care
is administered fails to prove the accuracy of assessment results. The
reimbursement shall be included in the finalized medical expenses and next
quarter extraprovincial reimbursement amount may be deducted.
c) In the event that the Social Security
Administration of the receiving province does not respond to the re-assessment
request, the North Center for medical assessing and billing shall adjust the
reimbursement in the next quarter.
d) By March 31st of every year, the
North Center for medical assessing and billing shall aggregate the previous
year reimbursement transfer notification and submit it to the Social Security
Administration of Vietnam (the Department of Finance and Accounting and the
Department of Health Insurance Policy) and the Social Security Administration
of the province as the basis for adjustment to extra-provincial reimbursement
for registered medical facilities and aggregation to medical expenses of the
Social Security Administration of the province.
Chapter VI
REPORTING REGIME, FORMS
AND DOCUMENTS
Article 18. Reporting forms
and documents
Required documents and reporting forms include:
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Forms No.C78-HD, C79a-HD, C79b-HD, C80a-HD,
C80b-HD, C81-HD, C82-CONTRACT and C86-HD issued together with Circular
No.178/2012/TT-BTC are adjusted in the Annex 02 issued together with this
Decision.
2. Forms and instructions
presented in Annex 01 issued together with this Decision.
Article 19. Reporting regime
1. Social Security
Administrations, medical facilities, and relevant agencies using primary
healthcare fund shall submit reports physically and electronically under
regulations of laws and shall be legally responsible for the legitimacy and
accuracy of their information and report.
2. Social Security shall
retain all documents and records under regulations of laws.
Article 20. Terms of reference
In case any legislative documents referred to this
Regulation is amended or supplemented, the new one shall prevail. /.