Circular No. 04/2021/TT-BYT guides the payment of costs for medical examination and treatment under health insurance based on fixed rates.

CIRCULAR

Guidelines for payment of outpatient and inpatient medical examination and treatment costs under health insurance at fixed rates

health insurance according to the standard rate

Pursuant to the Health Insurance Law No. 25/2008/QH12 dated November 14, 2008, amended and supplemented by Law No. 46/2014/QH13 dated June 13, 2014;

Pursuant to the Government's Decree No. 146/2018/NĐ-CP dated October 17, 2018 detailing and guiding the implementation of certain provisions of the Health Insurance Law;

Pursuant to the Government's Decree No. 75/2017/NĐ-CP dated June 20, 2017 stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;

At the proposal of the Director of the Department of Planning and Finance,

The Minister of Health issues this Circular on guidelines for payment of outpatient and inpatient medical examination and treatment costs under health insurance at fixed rates.

PART I

GENERAL PROVISIONS

Article 1. Scope of Regulation and Application

1. This Circular stipulates on:

a) Determining the fixed rate fund;

b) Transferring, temporarily advancing, and settling accounts for the fixed rate fund;

c) Monitoring indicators for implementing fixed rates.

2. This Circular does not apply to healthcare facilities (hereinafter referred to as facilities) that newly sign health insurance medical examination and treatment contracts in the preceding year.

Article 2. Interpretation of Terms

1. Fixed Rate Fund is the amount of money determined in advance, transferred to health insurance medical examination and treatment facilities for outpatient medical examinations and treatments for patients with health insurance cards within the scope of fixed rates during a specified period.

2. Age Group Participants in health insurance stipulated in this Circular are divided into six age groups based on their year of birth as follows:

a) Group 1: from 0 to 6 years old;

b) Group 2: from 7 to 18 years old;

c) Group 3: from 19 to 24 years old;

d) Group 4: from 25 to 49 years old;

đ) Group 5: from 50 to 59 years old;

e) Group 6: 60 years old and above.

3. Conversion Card is a health insurance card registered for initial medical examination and treatment that is converted to cover the time period of fund transfer and according to the cost of each age group within the scope of fixed rates as stipulated in Clause 2 of this Article.

4. Equivalent Card is a health insurance card with the same resource usage requirements for one medical examination and treatment session within the scope of fixed rates; the total number of equivalent cards of a facility is the sum of the number of outpatient medical examination and treatment sessions within the scope of fixed rates of insured patients who have initial and multi-level medical examinations and treatments at the facility, adjusted according to the age group and the number of conversion cards of the facility.

5. Basic Fee is the amount of funds used to pay for one equivalent card, applied nationwide or throughout a province or centrally administered city (hereinafter referred to as province).

6. Fund Transfer Coefficient is the coefficient used to adjust the provincial fixed rate fund (hereinafter referred to as k_;) or the facility fixed rate fund (hereinafter referred to as k_{THE UNIT}).

7. Surplus Amount is the difference between the settled fixed rate fund and the total outpatient medical examination and treatment costs under health insurance within the scope of fixed rates incurred by the facility at the end of the fund transfer period.

8. Increased or Decreased Costs Due to Policy Changes is the amount calculated separately for each facility when settling the costs of outpatient medical examinations and treatments under health insurance for the fund transfer year based on changes affecting the costs of outpatient medical examinations and treatments under health insurance due to legal regulations.

Article 3. Scope of Fixed Rates

1. The scope of fixed rates for facilities at the district level and below includes all costs of outpatient medical examinations and treatments within the benefit range of health insurance participants, except as provided in Clause 3 of this Article.

2. The scope of fixed rates for provincial and central facilities applies to all facilities with health insurance cards registered for initial medical examinations and treatments and all costs of outpatient medical examinations and treatments within the scope of fixed rates of patients registered for initial medical examinations and treatments occurring at the facility, except as provided in Clause 3 of this Article.

3. The scope of fixed rates does not include the following medical examination and treatment costs:

a) Costs of individuals with military personnel (QN), confidential service (CY), and police (CA) card codes;

b) Costs of transporting patients with health insurance cards;

c) All costs of outpatient medical examinations and treatments under health insurance using renal replacement therapy services or peritoneal dialysis services or peritoneal dialysis fluid;

d) All costs of outpatient medical examinations and treatments under health insurance using anti-cancer drugs or cancer intervention services for patients diagnosed with cancer, including codes C00 to C97 and D00 to D09 in the International Classification of Diseases, Tenth Revision (ICD-10);

đ) All costs of outpatient medical examinations and treatments under health insurance using hemophilia treatment drugs or blood or blood products for patients diagnosed with hemophilia, including codes D66, D67, and D68 in the ICD-10;

e) All costs of outpatient medical examinations and treatments under health insurance using organ transplant rejection prevention drugs for organ transplant patients;

g) All costs of outpatient medical examinations and treatments under health insurance using hepatitis C treatment drugs for hepatitis C patients;

h) All costs of outpatient medical examinations and treatments under health insurance using antiretroviral drugs or HIV viral load testing services for HIV-diagnosed patients with health insurance cards.

Chapter II

DETERMINATION OF THE FIXED RATE FUND

Article 4. National Standard Fund

1. The National Standard Fund (hereinafter abbreviated as QUY_ĐS tq) for the year transferring the fund shall be calculated according to the following formula:_tq) for the year of the fund transfer shall be calculated according to the following formula:

Where:

a) The total national standard fund of the preceding year that has been settled is the total amount within the scope of the national standard fund of each facility of the preceding year that has been settled as stipulated in this Circular;

b) The difference in amount due to an increase or decrease in exchange cards between the year transferring the fund and the preceding year shall be calculated according to the following formula:

Where:

- T_TTĐS of the entire country = Total payment settlement for standard rate (hereinafter abbreviated as T_TTĐS) of all provinces throughout the country;

- T_TTĐS of the province = Total T_TTĐS of all facilities implementing medical examination and treatment according to the standard rate of the province;

- T_TTĐS of the facility = (The standard fund of the facility for the year decided upon according to Article 11 of this Circular) + (The amount increased or decreased due to changes in policy factors stipulated in Clause 8, Article 2 of this Circular).

2. The number of exchange cards of the entire country, the card conversion factor of the entire country

a) The number of exchange cards of the entire country equals the total number of exchange cards of the provinces;

b) The number of exchange cards of the year transferring the fund of the province (hereinafter abbreviated as The QĐ tỉnh) = Total [(Number of health insurance registration cards for initial medical examination and treatment of the province of the year transferring the fund counted from January 1 to December 31 of the year transferring the fund) x (National card conversion factor of the age group of the year transferring the fund)];_province) = Total [Number of health insurance registration cards for initial medical examination and treatment by age group of the province for the year of the fund transfer from January 1 to December 31 of the year of the fund transfer x National conversion factor for that age group for the year of the fund transfer].

Where:

- i is the ith age group, where i has a value from 1 to 6 corresponding to the 6 age groups stipulated in Clause 2, Article 2 of this Circular;

- The ĐKBĐ year transferring the fund i is the health insurance registration card for initial medical examination and treatment of the ith age group of the provincial standard rate year transferring the fund that has been calculated for a full year;_;i is the health insurance registration card for initial medical examination and treatment of age group i for the year of the standard rate province which has been calculated for a full year;

- Conversion Factor_tq- HSQĐT i is the national card conversion factor of the ith age group of the year transferring the fund calculated according to the following formula:

Where:

Where:

- T_BHTT of the entire country = Total medical examination and treatment costs under health insurance that have been settled (hereinafter abbreviated as T_BHTT) of all provinces throughout the country;

- T_BHTT of the province = Total T_BHTT of all facilities implementing medical examination and treatment according to the standard rate of the province;

- T_BHTT of the facility = The amount determined according to the payment cost appraisal record for medical examination and treatment under health insurance within the scope of the health insurance fund of the provincial social insurance agency.

Article 5. National Basic Fee Rate

1. The national basic fee rate for the year of fund transfer (hereinafter referred to as SPCB) shall be calculated according to the following formula:_tq) shall be calculated according to the following formula:

Where:

a) QUY_ĐS_tq shall be implemented in accordance with Clause 1 of Article 4 of this Circular;

b) The NTQ_tq is the national equivalent card number of the year of fund transfer, which is the total equivalent card number of all provinces in the year of fund transfer.

2. The province's equivalent card number for the year of fund transfer = (The province's internal equivalent card number for the year of fund transfer) + (The province's multi-line equivalent card number to other provinces for the year of fund transfer).

a) The province's internal equivalent card number for the year of fund transfer is the total of the internal equivalent card numbers of the six age groups specified in Clause 2 of Article 2 of this Circular for that province. The province's internal equivalent card number group i for the year of fund transfer (hereinafter referred to as The TĐ internal province group i year of fund transfer) shall be calculated according to the following formula:

Where:

- Number of internal province group i visits_{province ntlk} is the number of visits of patients in group i with health insurance cards registered for initial health insurance examination and treatment at the province (excluding health insurance cards issued by other provinces) who went to medical facilities within the province in the preceding year;

- The QĐ group i_{province ntlk} is the number of converted cards of group i of the preceding year of the province;

- The QĐ group i_{province year of fund transfer} is the number of converted cards of group i of the year of fund transfer of the province;

- Conversion factor for group i visits_{nationwide year of fund transfer} is the nationwide conversion factor for group i visits of the year of fund transfer.

b) The province's multi-line equivalent card number to other provinces for the year of fund transfer is the total of the multi-line equivalent card numbers of the six age groups as stipulated in Clause 2 of Article 2 of this Circular.

c) The nationwide conversion factor for group i (hereinafter referred to as HSQĐL_tqi) of the year of fund transfer shall be calculated according to the following formula:

Where:

Article 6. Provincial Fixed Fund

1. The provincial fixed fund for the year of fund transfer (hereinafter referred to as QUY_ĐS_;) shall be calculated according to the following formula:

Where:

a) SPCB_tq shall be implemented in accordance with Clause 1 of Article 5 of this Circular;

b) The equivalent card number of the year of fund transfer of the province shall be implemented in accordance with Clause 2 of Article 5 of this Circular;

c) k1_; is the adjustment factor for the province's costs based on the average cost nationwide and ensuring the provisional fixed fund of the province according to the coefficient k = k1 (excluding coefficient k2) does not exceed 110% (one hundred ten percent) or is less than 90% (ninety percent) when having the same number of converted cards of the province, k1_; shall be calculated according to the following formula:

Where:

- TLHS is the ratio applying the cost coefficient according to the implementation schedule stipulated in Clause 2 of Article 15 of this Circular.

- CPBQ card TD_{province ntlk} is the average cost per equivalent card of the province in the preceding year, calculated according to the following formula:

- CPBQ card TD_{province ntlk} is the average cost per equivalent card of the whole country in the preceding year, calculated according to the following formula:

d) k2_đctqtq is the adjustment factor to ensure the total fixed fund allocated to all provinces of the whole country equals the total fixed fund of the whole country calculated according to the following formula:

Where:

- n is the number of provinces implementing the fund transfer for health examination and treatment according to the fixed quota;

- QUY_ĐS_tq shall be implemented in accordance with Clause 1 of Article 4 of this Circular;

- QUY DS_{province tt} is the provisional fixed fund of the province calculated according to coefficient k1 and adjusted to ensure it does not exceed 110% (one hundred ten percent) or is not less than 90% (ninety percent) compared to T_TTDS of the province in the preceding year on the same amount of converted cards (excluding coefficient k2) of the province;

- j is the order number of province j, where j has a value from 1 to n corresponding to the number of provinces implementing the fund transfer for health examination and treatment according to the fixed quota.

đ) k3_; is another adjustment factor of the province, k3_; shall be applied as 1 in the first year of implementation. In subsequent years, it will be regulated by the Minister of Health. In the absence of such regulations, k3_; shall be applied as 1.

2. The provincial fixed fund does not include increased or decreased costs due to changes in policy factors. Determination of increased or decreased costs due to changes in policy factors shall be carried out according to the notification of the Ministry of Health. In the absence of a notification from the Ministry of Health, increased or decreased costs due to changes in policy factors shall be considered as zero.

3. The provincial fixed fund will be fully allocated to all facilities in the year of fund transfer.

Article 7. Basic Fee Rate of the Province

1. The basic fee rate of the province for the year to be transferred (hereinafter referred to as SPCB) shall be implemented in accordance with Clause 1 of Article 6 of this Circular; it is the equivalent number of cards of the province for the year to be transferred._;) shall be calculated according to the following formula:

Where:

a) QUY_ĐS_; 2. The total equivalent number of cards of the province for the year to be transferred equals the sum of the equivalent number of cards of all institutions implementing the standard rate in the province for the year to be transferred.

b) The NTQ_province 3. The equivalent number of cards of an institution implementing the standard rate for the year to be transferred = (The equivalent number of cards for initial health check-up and treatment under health insurance at the institution for the year to be transferred) + (The equivalent number of cards for multi-level visits to the institution for the year to be transferred).

a) The equivalent number of cards for initial health check-up and treatment under health insurance of the institution for the year to be transferred is equal to the total equivalent number of cards for initial health check-up and treatment under health insurance according to six age groups as prescribed in Clause 2 of Article 2 of this Circular of the institution for the year to be transferred.

The equivalent number of cards for initial health check-up and treatment under health insurance of age group i for the year to be transferred of the institution is calculated according to the following formula:

Equivalent Card for Initial Health Check-Up and Treatment of the Institution Age Group i Year to be Transferred

Number of Visits for Initial Health Check-Up and Treatment Age Group i

Where:

- Conversion Card Age Group i_{Institution ntlk} is the number of conversion cards of age group i of the institution in the immediately preceding year;

is the number of conversion cards of age group i of the institution for the year to be transferred;_{Institution ntlk} is the conversion factor for visits of age group i throughout the province for the year to be transferred. The conversion factor for visits throughout the province by age group i for the year to be transferred is calculated according to the following formula:

is the number of conversion cards of age group i of the institution for the year to be transferred;_{- Number of Visits for Initial Health Check-Up and Treatment Age Group i} Conversion Factor for Visits Age Group i

- Conversion factor for group i visits _{is the number of visits of patients in age group i with health insurance cards registered for initial health check-up and treatment under health insurance at the institution and treated at the same institution in the immediately preceding year;} Average Cost Per Visit for Age Group i Throughout the Province in the Immediately Preceding Year

Where:

Article 8. Standard Rate Fund of the Institution

1. The standard rate fund of the institution for the year to be transferred is calculated according to the following formula:

Standard Rate Fund of the Institution

Equivalent Number of Cards of the Institution for the Year to be Transferred

Where:

a) SPCB_; is the cost adjustment factor of the institution based on the average cost throughout the province and ensuring that the provisional standard rate fund calculated according to coefficient k = k1 (without coefficient k2) does not exceed 110% or is less than 90% when having the same number of converted cards. k1 of the institution is calculated according to the following formula:

Provisional Standard Rate Fund of the Institution

c) k1_{implemented in accordance with Clause 1 of Article 7 of this Circular;} Equivalent Number of Cards of the Institution in the Immediately Preceding Year

Where:

- TLHS is the ratio applying the cost coefficient according to the implementation schedule stipulated in Clause 2 of Article 15 of this Circular.

- CPBQ card TD_{Institution ntlk} is the average cost per equivalent card of the province in the preceding year, calculated according to the following formula:

d) k2_{b) The equivalent number of cards of the institution for the year to be transferred implemented in accordance with Clause 3 of Article 7 of this Circular;} + PROVISED_STANDARD_RATE

implemented in accordance with Article 6 of this Circular;

Institution tt_province is the provisional standard rate fund of the institution calculated according to the coefficient k of the institution using k1 and adjusted to ensure that it does not exceed 110% or is not less than 90% compared to the costs of the immediately preceding year on the same amount of converted cards (excluding coefficient k2) of the institution;

Institution tt_{+ j is the serial number of institution j, where j has a value from 1 to n corresponding to the number of institutions implementing cost settlement and finalization for health check-up and treatment under health insurance according to the standard rate throughout the province.} is another adjustment factor of the institution, k3

applied at 1 in the first year of implementation. In subsequent years, it is determined by the Department of Health in coordination with the provincial Social Insurance agency. If there is no regulation, k3

đ) k3_{THE UNIT} 2. The standard rate fund of the institution does not include increased or decreased costs due to changes in policy factors. Determination of increased or decreased costs due to changes in policy factors is carried out according to the notification of the Ministry of Health. In the absence of a notification from the Ministry of Health, increased or decreased costs due to changes in policy factors are considered zero._{THE UNIT} TRANSFER, TEMPORARY PAYMENT, FINALIZATION OF THE STANDARD RATE FUND_{THE UNIT} shall be applied as 1.

2. The base standard rate fund does not include costs increased or decreased due to changes in policy factors. Determination of costs increased or decreased due to changes in policy factors shall be carried out according to the notification of the Ministry of Health. In case there is no notification from the Ministry of Health, costs increased or decreased due to changes in policy factors shall be considered zero.

Chapter III

TRANSFER, TEMPORARY PAYMENT, SETTLEMENT OF THE STANDARD RATE FUND

Article 9. Allocation of Fixed Fund to Provinces

1. Before January 15 of the allocation year, the Vietnam Social Security shall notify the provincial social security agencies about:

a) The provisional fixed fund of the province for the allocation year after reaching agreement with the Ministry of Health. The determination of the provisional fixed fund is carried out according to the provisions of Clause 2 of this Article;

b) The fixed fund of the province for the preceding year immediately before the allocation year.

2. The provisional fixed fund at the beginning of the year for the province is determined according to the provisions of Article 6 of this Circular, wherein the figures are temporarily calculated as follows:

a) The national fixed fund for the preceding year is provisionally settled by the total provisional national fixed fund of the preceding year;

b) The national basic premium rate at the beginning of the year = (95% (ninety-five percent) of the provisionally calculated national fixed fund at point a of this clause) : (the number of equivalent cards nationwide as stipulated in point b of Clause 1 of Article 5 of this Circular);

c) The number of converted cards of the preceding year of each province is temporarily calculated based on the number of issued cards of the social insurance agency of the preceding year of each province that have been converted according to the national card conversion factor;

d) The number of visits, T_BHTT of the province for the preceding year is temporarily calculated based on the number of visits, outpatient medical expenses within the fixed quota that the facility has proposed on the Medical Insurance Claim Information System of the preceding year of the province;

đ) T_TTĐS of the province for the preceding year is temporarily calculated based on the provisional annual fixed fund of the preceding year adjusted in the fourth quarter of the preceding year of the province;

e) The number of converted cards of the allocation year of each province is temporarily calculated based on the number of health insurance participants in the first quarter of the allocation year of each province that have been converted according to the national card conversion factor.

Article 10. Allocation of Fixed Fund to Facilities

1. Based on the notification of the provisional fixed fund of the province as stipulated in Clause 1 of Article 9 of this Circular, before January 30 of the allocation year, the provincial social security agency shall notify the facilities about:

a) The provisional fixed fund of the facility for the allocation year after reaching agreement with the Department of Health. The determination of the provisional fixed fund for each facility on the territory is carried out according to the provisions of Clause 3 of this Article;

b) The fixed fund of the facility for the preceding year immediately before the allocation year.

2. Based on the provisional fixed fund of each facility, the provincial social security agency shall be responsible for allocating the fixed fund to each facility quarterly as follows:

a) Allocate the fund for the first quarter before January 30 of the allocation year with an amount equal to 22% (twenty-two percent) of the provisional fixed fund;

b) Allocate the fund for the second quarter before April 15 of the allocation year with an amount equal to 24% (twenty-four percent) of the provisional fixed fund;

c) Allocate the fund for the third quarter before July 15 of the allocation year with an amount equal to 27% (twenty-seven percent) of the provisional fixed fund;

d) Allocate the fund for the fourth quarter before October 15 of the allocation year with an amount equal to 27% (twenty-seven percent) of the provisional fixed fund.

3. The provisional fixed fund at the beginning of the year for each facility is determined according to the provisions of Article 8 of this Circular, wherein the figures are temporarily calculated as follows:

a) The provisional fixed fund of the province is calculated as the total fixed fund announced at the beginning of the year;

b) The provincial basic premium rate = (95% (ninety-five percent) of the provisional fixed fund at the beginning of the year) : (the number of equivalent cards throughout the province as stipulated in Clause 2 of Article 7 of this Circular);

c) The number of converted cards of the preceding year of each facility is temporarily calculated based on the number of issued cards of the social insurance agency of the preceding year that have been converted according to the provincial card conversion factor;

d) The number of visits, T_BHTT of the facility for the preceding year is temporarily calculated based on the number of visits, outpatient medical expenses within the fixed quota that the facility has proposed on the Medical Insurance Claim Information System of the preceding year of the facility;

đ) T_TTĐS of the facility for the preceding year is temporarily calculated based on the provisional annual fixed fund of the preceding year adjusted in the fourth quarter of the preceding year of the facility;

e) The number of converted cards of the allocation year of each facility is temporarily calculated based on the number of initial outpatient medical service registration for health insurance in the first quarter of the allocation year and converted according to the provincial card conversion factor.

Article 11. Settlement of fixed-rate fund for the facility

1. The fixed-rate fund of the facility shall be settled quarterly based on the amount allocated to the facility as stipulated in Clause 2, Article 10 of this Circular.

2. The annual fixed-rate fund of the facility shall be settled by the amount determined under Article 8 of this Circular when the facility simultaneously meets the following ratios:

a) The ratio of inpatient transfers within the fixed rate not exceeding the previous year;

b) The frequency of multi-level outpatients of patients registered for initial medical examination and treatment not exceeding the previous year;

c) The ratio of multi-level patient transfers for outpatient medical examination and treatment at provincial and central levels within the fixed rate allocation year not exceeding the previous year;

3. In case the facility does not meet the provisions of Clause 2 of this Article, the annual fixed-rate fund of the facility shall be settled = (the amount of the fund determined according to the provisions of Article 8 of this Circular) - (the amount to be deducted determined according to the provisions of Articles 12 and 13 of this Circular corresponding to the increase ratio);

Example:

- If the facility has an increased ratio of inpatient transfers, the amount to be deducted shall be determined according to the provisions of Article 12 of this Circular;

- If the facility has an increased frequency of multi-level outpatients of patients registered for initial medical examination and treatment, the amount to be deducted shall be determined according to the provisions of Clause 1, Article 13 of this Circular;

- If the facility has an increased ratio of inpatient transfers and an increased frequency of multi-level outpatients of patients registered for initial medical examination and treatment, the amount to be deducted shall be the sum of the amounts determined according to the provisions of Article 12 of this Circular and the amount determined according to the provisions of Clause 1, Article 13 of this Circular;

4. The difference in funds between the temporarily allocated fixed-rate funds for quarters I, II, and III and the settled annual fixed-rate fund of the facility shall be adjusted by the health insurance fund during the settlement period of the fourth quarter fixed-rate fund.

5. In case the facility terminates the outpatient medical examination and treatment insurance contract during the implementation year, the amount of the settled fixed-rate fund shall correspond to the time of implementing the fixed rate.

6. In case the fixed-rate fund allocated during the implementation year exceeds the actual costs of medical examination and treatment under the insurance (surplus fixed-rate fund):

a) The maximum amount of surplus fixed-rate fund retained by the facility is 20% (twenty percent) of the total annual fixed-rate fund allocated to the facility and is included in the calculation of the fixed-rate fund for the next year. The remaining surplus after the facility retains 20% (if applicable) will be transferred to the provincial fixed-rate fund and will not be included in the calculation of the fixed-rate fund for the facility for the next year;

b) The facility records the surplus amount specified in point a of this clause into its revenue sources. Management and use of this surplus portion shall be carried out in accordance with the law;

c) If the fixed-rate fund of the facility includes the costs of medical examination and treatment of affiliated facilities, the facility is responsible for allocating a portion of the surplus funds retained by the facility to the affiliated facilities. The Department of Health shall take the lead in coordinating with the Provincial Social Insurance to guide the allocation of the surplus portion to each affiliated facility in accordance with the actual conditions of each locality;

7. In case the allocated fixed-rate fund is less than the expenses for medical examination and treatment under the insurance within the fixed rate (the facility incurs a deficit in the fixed-rate fund), the facility shall balance the deficit from its revenue sources in accordance with the regulations;

Chapter IV

MONITORING INDICATORS FOR IMPLEMENTATION OF FIXED RATE

Article 12. Provisions on the Inpatient Treatment Ratio

1. The inpatient treatment ratio is determined according to the following formula:

For provincial-level and central-level facilities, the number of inpatient treatments only counts cases where patients have registered for initial health insurance examination and treatment at the facility.

In cases where the facility implements payment based on fixed rates and the inpatient transfer ratio for the year exceeds the inpatient transfer ratio of the previous year, each excess case will be deducted an amount corresponding to the average cost per inpatient treatment under health insurance at the facility.

2. The number of inpatient treatments exceeding the limit is calculated according to the following formula:

Article 13. Provisions on the Multi-Level Outpatient Ratio and Transfer Ratio

1. The multi-level outpatient ratio of patients who have registered for initial health insurance examination and treatment (hereinafter referred to as the multi-level outpatient ratio) at a facility within a year (denoted as n) equals (=) the number of health insurance examination and treatment cases of cardholders who have registered for initial health insurance examination and treatment at the facility and go to other facilities within the fixed rate range for health insurance examination and treatment (excluding cases going to district-level facilities within the province for health insurance examination and treatment) in year (n), divided by (:) the number of conversion cards in year (n) of the facility.

The number of multi-level outpatient visits exceeding the multi-level outpatient ratio of the previous year is calculated according to the following formula:

In cases where the facility implements payment based on fixed rates and the multi-level outpatient ratio exceeds the multi-level outpatient ratio of the previous year, each excess visit will be deducted an amount corresponding to the average cost per outpatient health insurance examination and treatment case within the fixed rate range for multi-level outpatient visits in the budget year of the facility.

2. The transfer ratio of multi-level patients arriving at the facility in year (n) is calculated according to the following formula:

Where:

For provincial-level and central-level facilities, the transfer ratio of multi-level patients arriving is not applied.

In cases where the facility implements payment based on fixed rates and the transfer ratio exceeds the transfer ratio of the previous year, each increase beyond the limit will be deducted an amount corresponding to the average cost per outpatient health insurance examination and treatment case within the fixed rate range for transfer cases in the budget year of the facility.

3. Facilities receiving patients for health insurance examination and treatment from other facilities that have been transferred must have complete information on the code of the facility transferring the patient (MA_NOI_CHUYEN) as stipulated in Table 1 of the Appendix issued together with Decision No. 4210/QĐ-BYT dated September 20, 2017 of the Ministry of Health regarding the Standards and Data Format for Use in Management, Verification, and Payment of Costs for Health Insurance Examination and Treatment. In cases where the health insurance payment application for correct-line transfer does not include this code, the application will not be considered a correct-line transfer case and will be paid according to the current regulations for incorrect-line transfer cases.

Chapter V

IMPLEMENTING PROVISIONS

Article 14. Effective Date

This Circular takes effect from July 1, 2021.

Article 15. Transitional Provisions and Implementation Timeline

1. The defined quota fund for the year 2021 shall be calculated from January 1, 2021, wherein the data to calculate the defined quota fund for 2021 shall be implemented according to the following regulations:

a) The equivalent number of cards of the facility, of the province due to an increase or decrease in exchangeable cards determined based on the difference in the number of exchangeable cards in 2021 compared to 2019;

b) The total defined quota fund nationwide for 2021 as stipulated in Clause 1, Article 4 of this Circular shall be calculated according to the following formula:

Where:

- CP is the amount spent on health insurance medical examination and treatment within the defined quota in 2019 settled according to the provisions of Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government detailing and guiding methods to implement the Health Insurance Law (hereinafter referred to as Decree No. 146/2018/ND-CP);

- TL is the ratio of expenses for health insurance medical examination and treatment within the defined quota in the total expenses for health insurance medical examination and treatment under the responsibility of the social insurance agency in 2019.

c) T_BHTT of the preceding year equals T_BHTT of 2019;

d) T_TTDS of the preceding year equals T_BHTT of 2019;

đ) The monitoring indicators for facilities are determined based on the data of 2019, including:

- The multi-level referral rate, the transfer-out rate of the preceding year are determined based on the multi-level referral rate, the transfer-out rate of 2019;

- The admission rate for inpatient treatment of the preceding year equals the number of health insurance medical examination and treatment sessions within the defined quota of the facility in 2019 divided by the total number of health insurance medical examination and treatment sessions (including both inpatient and outpatient) of the facility in 2019.

2. Implementation timeline for the application ratio of cost coefficients:

a) In 2021: the application ratio of cost coefficients is 80%;

b) From 2022 onwards: Implemented according to the notification of the Ministry of Health. In case there is no notification, continue applying the application ratio of cost coefficients of the preceding year.

Article 16. Reference Clauses

In cases where the referenced documents in this Circular are replaced or amended, they shall be implemented according to the replaced or amended documents.

Article 17. Responsibility for Implementation

1. Responsibilities of the Ministry of Health:

a) Conduct verification and reconciliation before transferring the defined quota fund to provinces regarding the calculation results of the national defined quota fund, relevant indices, allocation coefficients, and other related coefficients of the Vietnam Social Security for provinces based on actual data used;

b) Specify and announce coefficient k3;_;;

c) Take the lead and coordinate with the Vietnam Social Security to calculate the costs of health insurance medical examination and treatment within the defined quota when affected by policy factors related to the settlement and payment of medical examination and treatment costs;

d) Direct facilities to strictly comply with professional regulations, implement comprehensive measures to ensure the rational, safe, and effective use of the defined quota fund;

đ) Organize implementation, inspection, audit, supervision, evaluation, and summary of the implementation of this Circular throughout the country.

2. Responsibilities of the Vietnam Social Security:

a) Lead the calculation of the national defined quota fund, conversion coefficients, allocation coefficients, and other related coefficients for provincial allocation of the defined quota fund; unify with the Ministry of Health before announcing the defined quota fund to provinces;

b) Provide the Ministry of Health with the data used for calculation, calculation method, allocation, and transfer of the defined quota fund for inspection and reconciliation;

c) In case the total expenditure within the national defined quota fund exceeds the allocated defined quota fund, the Vietnam Social Security will compile and report according to Clause 6, Article 25 of Decree No. 146/2018/ND-CP;

d) Announce the defined quota fund to provinces;

đ) Direct the Vietnam Social Security Province:

- To implement the payment method according to the defined quota as prescribed and guided in this Circular;

- Lead and coordinate with the Department of Health to determine the indices: number of health insurance cards registered for initial medical examination and treatment, card conversion coefficient, basic fee of the province, allocation coefficient of each facility, and other related coefficients according to the guidance of the Ministry of Health and the Vietnam Social Security;

- Coordinate with healthcare facilities providing health insurance medical examination and treatment in organizing implementation according to this Circular;

- Coordinate with the Department of Health in inspecting, supervising, ensuring patient benefits with health insurance cards, supervising the implementation of this Circular by healthcare facilities implementing defined quota payments, resolving arising issues within their authority during the implementation process;

- Coordinate with the Department of Health to guide healthcare facilities signing contracts for medical examination and treatment according to the defined quota payment method to handle surplus or deficit of the defined quota fund (if any) for subordinate facilities.

e) Develop appropriate review methods suitable for the defined quota payment method, instruct the Vietnam Social Security Province to implement and supervise, ensuring patient benefits with health insurance cards.

3. Responsibilities of the People's Committee at the provincial level:

Promptly direct and resolve difficulties and obstacles within their duties during the implementation of health insurance policies and matters related to this Circular.

4. Responsibilities of the Department of Health:

a) Direct healthcare facilities providing health insurance medical examination and treatment in the locality to implement this Circular;

b) Conduct verification and reconciliation before transferring the defined quota fund to facilities regarding the calculation results of the provincial defined quota fund and the transfer of the defined quota fund by the Vietnam Social Security Province to facilities based on actual data used;

c) Coordinate with the Vietnam Social Security Province to determine the indices: number of health insurance cards registered for initial health insurance medical examination and treatment, card conversion coefficient, basic fee of the province, allocation coefficient of healthcare facilities, and other related coefficients according to the guidance of the Ministry of Health;

d) Lead and coordinate with the Vietnam Social Security Province in directing healthcare facilities to organize implementation of this Circular at multi-disciplinary clinics and commune health stations under the facilities.

đ) Chair and coordinate with the Social Insurance of the province in inspecting, supervising, ensuring benefits for patients with health insurance cards, monitoring the implementation of this Circular by healthcare facilities that settle payments based on fixed rates, and resolving arising issues within their authority;

e) Chair and coordinate with the Social Insurance of the province to guide healthcare facilities that have signed contracts for medical examination and treatment under the fixed-rate method to handle surplus or deficit funds from the fixed-rate fund (if any) for subordinate facilities in accordance with local realities;

5. Responsibilities of healthcare facilities:

a) Direct units and individuals under their management to study and implement this Circular;

b) Ensure benefits for insured patients, provide sufficient and timely medicines, chemicals, and medical supplies within the scope of benefits for insured persons;

c) In cases where the surplus fixed-rate fund exceeds 25% (twenty percent) of the temporarily assigned fixed-rate fund at the beginning of the year, the facility must submit a written explanation to the Department of Health and the Social Insurance of the province. The Department of Health and the Social Insurance of the province will organize an assessment of the quality of treatment to ensure the rights of insured persons;

d) Implement coding and transferring electronic data related to the implementation of the fixed-rate payment method as prescribed;

đ) Handle surplus or deficit funds from the fixed-rate fund according to the guidance of the Department of Health;

e) Allocate the fund to subordinate facilities but not exceeding the total fixed-rate fund assigned to the facility;

g) Proactively use the determined budget for the year to provide medical services to patients with health insurance cards;

During the implementation process, if there are difficulties or inconveniences, relevant agencies, units, organizations, and individuals are requested to promptly report to the Ministry of Health (Department of Planning and Finance) for consideration and resolution./.