Circular No. 10/2009/TT-BYT guiding registration for initial medical examination and treatment and referral under health insurance

CIRCULAR

Guidelines for registering initial medical examination and treatment and transferring for medical examination and treatment under health insurance

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Pursuant to the Health Insurance Law No. 25/2008/QH12 dated November 14, 2008;

Pursuant to the Government Decree No. 188/2007/NĐ-CP dated December 27, 2007 on the functions, tasks, powers, and organizational structure of the Ministry of Health;

Pursuant to the Government Decree No. 62/2009/NĐ-CP dated July 27, 2009 detailing and guiding the implementation of certain provisions of the Health Insurance Law;

Pursuant to the Joint Circular No. 09/2009/TTLT-BYT-BTC dated August 14, 2009 of the Ministry of Health and the Ministry of Finance on implementing health insurance;

The Ministry of Health guides the registration for initial medical examination and treatment and the transfer for medical examination and treatment under health insurance as follows:

I. HEALTH INSURANCE REGISTRATION FACILITIES FOR MEDICAL EXAMINATION AND TREATMENT

INITIAL HEALTH INSURANCE

Article 1. Primary healthcare facilities at the commune level and equivalent

1. Commune health stations.

2. Health stations, medical units of agencies, units, and schools.

Article 2. Medical examination and treatment facilities at the district level and equivalent

1. District health centers (with medical examination and treatment functions), district general hospitals, county general hospitals, town general hospitals, and provincial city general hospitals.

2. Health centers with beds, police provincial health stations, military unit health stations, general hospitals of Class III, Class IV, or not yet classified under the health sector (including state-owned corporations, state-owned enterprises, and state-owned holding companies).

3. Health centers with beds, general hospitals of Class III, Class IV, or not yet classified under specialized medical academies and schools.

4. Private general hospitals of Class III, Class IV, or not yet classified.

5. Regional multi-specialty clinics under district health centers or county hospitals.

6. Multi-specialty clinics under agencies, units, schools, and health centers of ministries and sectors.

7. Private multi-specialty clinics.

Article 3. Medical examination and treatment facilities at the provincial level and equivalent

1. Provincial general hospitals, centrally governed cities' general hospitals.

2. Regional general hospitals under the Department of Health.

3. Specialized hospitals under the Department of Health with outpatient departments having general medical examination functions.

4. General hospitals of Class II under specialized medical academies and schools.

5. Private general hospitals of Class II.

6. General hospitals of Class II under ministries and sectors.

7. Clinics of the Provincial/City Cadre Health Care Board.

Article 4. Medical examination and treatment facilities at the central level and equivalent

1. General hospitals directly under the Ministry of Health.

2. Specialized hospitals directly under the Ministry of Health with outpatient departments having general medical examination functions.

3. General hospitals of Class I under specialized medical academies and schools.

4. General hospitals of Class I directly under ministries and sectors.

5. Private general hospitals of Class I.

6. Vietnam Friendship Hospital, Thong Nhat Hospital, and Da Nang C Hospital directly under the Ministry of Health.

Article 5. Conditions for primary medical examination and treatment health insurance facilities

1. Medical examination and treatment facilities specified in Clause 2 of Article 1 of this Circular must have sufficient human resources, infrastructure, and equipment to meet the needs of routine medical examination and treatment in internal medicine, surgery, and initial emergency care within the scope of their expertise.

2. Medical examination and treatment facilities specified in Clauses 6 and 7 of Article 2 of this Circular must have sufficient human resources, infrastructure, and equipment to meet the needs of routine medical examination and treatment in internal medicine, surgery, dermatology, ophthalmology, otolaryngology, stomatology, and initial emergency care.

3. Medical examination and treatment facilities specified in Clause 3 of Article 3 and Clause 2 of Article 4 of this Circular must have outpatient departments with general medical examination functions (as prescribed by competent state authorities).

II. REGISTRATION FOR INITIAL MEDICAL EXAMINATION AND TREATMENT FOR

HEALTH INSURANCE PARTICIPANTS

Article 6. Registration for initial medical examination and treatment at commune-level and district-level medical facilities and equivalent facilities

Clause 1. Persons participating in health insurance have the right to register for initial medical examination and treatment at one of the medical facilities specified in Articles 1 and 2 of this Circular.

Clause 2. In cases where persons participating in health insurance must work on a temporary basis or reside temporarily in another locality, they are entitled to undergo initial medical examination and treatment at medical facilities in that locality which are equivalent to the level of specialized technical skills indicated on their health insurance card.

Article 7. Registration for initial medical examination and treatment at provincial-level and central-level medical facilities

Clause 1. Persons participating in health insurance may register for initial medical examination and treatment at one of the medical facilities specified in Clauses 1, 2, 3, 4, 5, and 6 of Article 3 and Clauses 1, 2, 3, and 4 of Article 4 of this Circular under the following circumstances:

Point a. Persons who are domiciled, temporarily residing, or working in a district, town, or city within a province without medical facilities as specified in Articles 1 and 2 of this Circular or those facilities cannot meet the needs for initial medical examination and treatment for persons participating in health insurance;

Point b. Persons who are domiciled, temporarily residing, or working in a district, town, or city within a province with medical facilities as specified in Clauses 1, 2, 3, 4, 5, and 6 of Article 3 and Clauses 1, 2, 3, and 4 of Article 4 of this Circular may register for initial medical examination and treatment at those facilities according to the regulations of the Provincial Health Department Director.

Clause 2. Persons participating in health insurance who fall under the category managed and protected for health care according to Guideline No. 52 HD/BTCTW dated December 2, 2005 of the Central Organization Department of the Communist Party of Vietnam regarding the adjustment and supplementation of groups eligible for medical examination and treatment at certain central medical facilities may choose to register for initial medical examination and treatment at Bach Mai Hospital, Ho Chi Minh City General Hospital, or Da Nang Hospital C.

Clause 3. Persons under the management and protection of health care for cadres at the provincial or municipal level may register for initial medical examination and treatment at the outpatient clinic of the Cadre Health Care Board of the province or municipal general hospital.

Clause 4. Persons who have rendered meritorious service to the revolution and those aged 85 years or older may choose to register for initial medical examination and treatment at one of the medical facilities specified in Clauses 1, 2, 3, 4, 5, and 6 of Article 3 and Clauses 1, 2, 3, and 4 of Article 4 of this Circular.

Clause 5. Children under six years old may choose to register for initial medical examination and treatment at provincial or municipal general hospitals or pediatric hospitals.

III. TRANSFER FOR MEDICAL EXAMINATION AND TREATMENT UNDER HEALTH INSURANCE

Article 8. Transfer for medical examination and treatment under health insurance

Clause 1. Patients holding health insurance cards may be transferred for medical examination and treatment according to the severity of their illness, in accordance with the scope of expertise and technical classification in medical examination and treatment as prescribed by the Minister of Health.

Clause 2. In cases where medical facilities have been approved for certain technical services but are unable to perform them due to objective reasons, such medical facilities are permitted to transfer patients to other health insurance medical facilities capable of performing those techniques for treatment.

Clause 3. In cases where patients have been treated and need continued observation and treatment but exceed the capacity of the medical facility (overload situation), the medical facility is permitted to transfer patients to other health insurance medical facilities capable of providing emergency care and treatment.

Clause 4. In cases where patients have been treated and stabilized but require further treatment, observation, and care, they may be transferred to the health insurance medical facility where the patient was referred to, or the initial health insurance medical facility, or another health insurance medical facility if it agrees to accept and treat the patient.

Clause 5. Cases of transferring between medical facilities across adjacent localities shall be regulated by the Provincial Health Department Director.

Article 9. Procedures for Referral

1. Medical examination and treatment establishments shall implement referral procedures in accordance with the regulations of the Minister of Health.

2. In cases where referral is made at the request of the patient, the medical examination and treatment establishment transferring the patient must provide information to the patient regarding the scope of benefits and the level of payment for medical examination and treatment costs under health insurance when seeking medical examination and treatment outside the designated technical specialty route.

IV. IMPLEMENTATION PROVISIONS

Article 10. Responsibilities of the Department of Health

1. To take the lead and coordinate with the Social Insurance of the province/city:

a) To determine medical examination and treatment establishments that meet the conditions to organize initial medical examination and treatment under health insurance as stipulated in Clause 2, Article 1; Clauses 6 and 7, Article 2 and Clause 3, Article 3 of this Circular;

b) To compile a list of establishments meeting the conditions to participate in initial medical examination and treatment under health insurance within the province/city as a basis for the Social Insurance of the province/city to sign contracts for initial medical examination and treatment under health insurance;

c) To specify the procedures for referral for medical examination and treatment under health insurance among medical examination and treatment establishments within the province/city;

d) To unify and specify the procedures for referral for medical examination and treatment under health insurance among certain medical examination and treatment establishments in border areas within the province and between provinces, ensuring compatibility with the technical specialty route, the capacity of the medical examination and treatment establishments, convenience for patients, and suitability with the payment of medical examination and treatment costs by the Social Insurance of the province/city.

2. To direct medical examination and treatment establishments to conduct medical examination and treatment for health insurance participants in accordance with current regulations and to specify the procedures for referral among medical examination and treatment establishments within the province/city for health insurance patients.

3. Based on the actual conditions of the locality and the capacity of medical examination and treatment establishments, the Department of Health shall take the lead and coordinate with the Social Insurance of the province/city to specify the categories and number of health insurance participants eligible to register for initial medical examination and treatment under health insurance at the point b, Clause 1, Article 7 of this Circular to ensure the quality of medical examination and treatment and avoid overload.

Article 11. Responsibilities of Health Departments of Ministries and Sectors

1. The Military Medicine Bureau of the Ministry of National Defense and the Health Service of the Ministry of Public Security shall direct subordinate medical examination and treatment establishments that meet the conditions to organize initial medical examination and treatment under health insurance to register with the provincial Department of Health.

2. Other health departments:

a) To direct subordinate medical examination and treatment establishments located in provinces/cities, based on assigned tasks and the expertise of the establishments, to register with the provincial Department of Health to be recognized as meeting the conditions to organize initial medical examination and treatment under health insurance;

b) To coordinate with the provincial Department of Health and the Social Insurance of the province/city in guiding the implementation of registration for initial medical examination and treatment under health insurance and organizing medical examination and treatment under health insurance in accordance with regulations.

Article 12. Responsibilities of Provincial/City Social Insurances

1. To organize the signing of contracts for medical examination and treatment under health insurance with medical examination and treatment establishments that meet the conditions to organize initial medical examination and treatment under health insurance according to the list approved by the provincial Department of Health.

2. To guide health insurance participants to register or change their initial medical examination and treatment establishments within the province/city, ensuring that the number of participants registered at each establishment is appropriate to the capacity of the medical examination and treatment establishment.

Article 13. Transitional Provisions

1. To facilitate health insurance participants and save costs when changing cards, health insurance participants who have registered for initial medical examination and treatment at the establishment listed on their health insurance card before the effective date of this Circular shall continue to receive initial medical examination and treatment at that establishment until the expiration date listed on the card.

2. In cases where health insurance participants change their health insurance card from October 1, 2009, they shall be implemented in accordance with the guidance provided in this Circular.

Article 14. Effective Date

This Circular takes effect from October 1, 2009.

During the implementation process, if there are difficulties or obstacles, units are requested to report to the Ministry of Health for consideration and resolution./.