Decree No. 105/2014/ND-CP detailing and guiding the implementation of certain articles of the Health Insurance Law.

DECREE

Detailed regulations and guidance on implementing certain provisions of the Health Insurance Law

_______________________

Pursuant to the Law on Organization of the Government dated December 25, 2001;

Pursuant to the Health Insurance Law dated November 14, 2008 and the Law Amending and Supplementing Certain Provisions of the Health Insurance Law dated June 13, 2014;

At the proposal of the Minister of Health,

The Government promulgates the Decree detailing and guiding the implementation of certain provisions of the Health Insurance Law.

PART I

OBJECTS, CONTRIBUTION LEVELS, SUPPORT LEVELS AND SOURCES OF FUNDS FROM THE STATE BUDGET FOR CONTRIBUTIONS TO HEALTH INSURANCE

METHODS OF CONTRIBUTION AND BENEFIT LEVELS UNDER HEALTH INSURANCE

In addition to the objects specified in Clauses 1, 2, 3, 4, and Clause 5 of Article 12 amended and supplemented by the Health Insurance Law, other objects specified in Clause 6 of Article 12 amended and supplemented by the Health Insurance Law include:

1. Rubber workers currently receiving monthly allowances pursuant to Decision No. 206/CP dated May 30, 1979 of the Council of Ministers (now the Government) on policies for rubber workers who have ceased work due to old age and health issues shall participate in health insurance according to Clause 2 of Article 12 amended and supplemented by the Health Insurance Law.

2. Members of households engaged in agriculture, forestry, fisheries, and salt production with average living standards shall participate in health insurance according to Clause 4 of Article 12 amended and supplemented by the Health Insurance Law.

Article 2. Contribution levels for health insurance

1. From January 1, 2015, contribution levels for health insurance per month for the specified objects are as follows:

a) Equal to 4.5% of the monthly salary of the worker for the object specified in Point a of Clause 1 of Article 12 amended and supplemented by the Health Insurance Law. Workers during their maternity leave period according to the laws on social insurance shall contribute at a rate of 4.5% of their monthly salary before taking maternity leave;

Workers during their sick leave period of 14 days or more per month according to the laws on social insurance shall not be required to contribute to health insurance but still enjoy health insurance benefits;

Workers during their detention, temporary suspension from work for investigation, or examination to determine whether they violated the law shall contribute at a rate of 4.5% of 50% of their monthly salary as stipulated by law. If the competent authority concludes that there was no violation of the law, the worker must make up the health insurance contributions based on the salary recovered;

Workers during their study or work abroad shall not be required to contribute to health insurance; this time shall be counted as continuous participation in health insurance until the decision to return to work is issued by the organization sending them abroad;

Workers working abroad shall not be required to contribute to health insurance; within 60 days from the date of entry back into the country, if they participate in health insurance, the entire time spent working abroad and the time from returning to the country to the date of rejoining health insurance shall be counted as continuous participation in health insurance;

Workers during the period of processing to receive unemployment benefits according to the Labor Law, if they do not participate in health insurance under other groups, this period shall be counted as participation in health insurance;

b) Equal to 4.5% of the minimum wage for the object specified in Point b of Clause 1 of Article 12 amended and supplemented by the Health Insurance Law.

c) Equal to 4.5% of the pension or disability allowance for the object specified in Point a of Clause 2 of Article 12 amended and supplemented by the Health Insurance Law.

d) Equal to 4.5% of the minimum wage for the objects specified in Points b and c of Clause 2 of Article 12 amended and supplemented by the Health Insurance Law and the object specified in Clause 1 of this Decree.

đ) Equal to 4.5% of the unemployment benefit for the object specified in Point d of Clause 2 of Article 12 amended and supplemented by the Health Insurance Law.

e) Equal to 4.5% of the minimum wage for the objects specified in Points b, c, d, đ, e, g, h, i, k, l, m, and Point n of Clause 3; Clause 4 and Clause 5 of Article 12 amended and supplemented by the Health Insurance Law and the object specified in Clause 2 of this Decree.

For children aged 72 months who have not yet reached the school enrollment period, the health insurance card remains valid until September 30 of that year without requiring health insurance contributions.

g) The contribution level for all members of the household specified in Clause 5 of Article 12 amended and supplemented by the Health Insurance Law is as follows: The first person contributes at 4.5% of the minimum wage; the second, third, and fourth persons contribute sequentially at 70%, 60%, and 50% of the first person's contribution; from the fifth person onwards, the contribution is at 40% of the first person's contribution.

For households supported by the state budget for contributions, the reduction in contribution levels as stipulated in Point g of Clause 1 of this Article shall not apply.

2. Based on actual circumstances, the Ministry of Health shall take the lead and coordinate with the Ministry of Finance and relevant agencies to submit to the Government proposals to adjust health insurance contribution levels to ensure balance in the health insurance fund.

Article 3. The level of state budget funds to support health insurance premiums for certain groups

1. The level of support for health insurance premiums for persons belonging to near-poor households as stipulated in Point a Clause 4 Article 12 amended and supplemented by the Health Insurance Law shall be as follows:

a) Support 100% of the health insurance premium for persons belonging to near-poor households who have recently escaped poverty, with the support period being five years after escaping poverty. In cases where persons belonging to near-poor households had escaped poverty before January 1, 2015 but the time elapsed since their escape from poverty until January 1, 2015 was less than five years, the remaining support period shall be at least one year;

b) Support 100% of the health insurance premium for persons belonging to near-poor households currently residing in poor districts as defined in Resolution No. 30a/2008/NQ-CP dated December 27, 2008 of the Government on the Program to Rapidly and Sustainably Reduce Poverty in 61 Poor Districts and Districts with High Rates of Poor Households, which apply investment infrastructure policies according to Resolution No. 30a/2008/NQ-CP dated December 27, 2008 of the Government;

c) Support a minimum of 70% of the health insurance premium for persons belonging to near-poor households remaining under this category.

2. Provide a minimum of 30% support for health insurance premiums for students and trainees as stipulated in Point b Clause 4 Article 12 amended and supplemented by the Health Insurance Law.

3. Provide a minimum of 30% support for health insurance premiums for persons belonging to households engaged in agriculture, forestry, fisheries, and salt production with average living standards as specified in Decision No. 32/2014/QĐ-TTg dated May 27, 2014 of

4. Provincial People's Committees (hereinafter referred to as Provincial People's Committee) shall base on local budget capacity and other legitimate sources, including 20% of the medical examination and treatment funding allocated but not utilized in the year according to Clause 3 Article 35 amended and supplemented by the Health Insurance Law (if applicable), to develop and submit to the Provincial People's Council for decision on providing higher levels of support for health insurance premiums for the groups specified in Points c Clause 1, Clause 2, and Clause 3 of this Article.

Chapter II

LEVEL OF HEALTH INSURANCE BENEFITS AND METHODS FOR PAYING MEDICAL EXAMINATION AND TREATMENT FEES UNDER HEALTH INSURANCE

Article 4. Level of health insurance benefits for cases stipulated in Clause 1 and Clause 7 Article 22 amended and supplemented by the Health Insurance Law

1. Participants in health insurance when undergoing medical examinations and treatments as stipulated in Articles 26, 27, and Article 28 of the Health Insurance Law and Clause 4, Clause 5 Article 22 amended and supplemented by the Health Insurance Law shall be reimbursed by the health insurance fund for medical examination and treatment costs within the scope of benefits with the following levels of reimbursement:

a) 100% of medical examination and treatment costs for the groups specified in Points d, e, g, h, and Point i Clause 3 Article 12 amended and supplemented by the Health Insurance Law;

b) 100% of medical examination and treatment costs and no application of limits on the percentage of payment for certain drugs, chemicals, medical supplies, and technical services as prescribed by the Minister of Health for: Persons participating in revolutionary activities before January 1, 1945; persons participating in revolutionary activities from January 1, 1945 to August 1945; Mothers of Vietnam Heroic; war invalids, persons receiving benefits equivalent to war invalids, class B war invalids, disabled veterans with a reduction in work capacity of 81% or more; war invalids, persons receiving benefits equivalent to war invalids, class B war invalids when treating recurrent injuries or illnesses; children under six years old;

c) 100% of medical examination and treatment costs at commune-level facilities;

d) 100% of medical examination and treatment costs for cases where the cost of a single medical examination and treatment session is lower than 15% of the basic wage;

đ) 100% of medical examination and treatment costs for patients who have continuously participated in health insurance for five years from the time they joined health insurance to the time of medical examination and treatment, and whose cumulative out-of-pocket expenses for medical examination and treatment exceed six months' worth of the basic wage, calculated from the time they have been continuously enrolled in health insurance for five years, except in cases where they seek medical examination and treatment outside their designated level;

e) 95% of medical examination and treatment costs for the groups specified in Point a Clause 2, Point k Clause 3, and Point a Clause 4 Article 12 amended and supplemented by the Health Insurance Law;

g) 80% of medical examination and treatment costs for other groups.

2. Participants in health insurance when undergoing medical examinations and treatments at border healthcare facilities between two provinces or centrally governed cities (hereinafter referred to as provinces or cities) shall be reimbursed by the health insurance fund within the scope of rights and benefits as stipulated in Clause 1 of this Article, in the following cases:

a) Medical examinations and treatments at commune health stations, multi-disciplinary clinics, and district hospitals;

b) Referrals for specialized technical care at commune, district, and provincial levels.

The Chairman of the Provincial People's Committee shall direct the Department of Health to take the lead and coordinate with the Social Insurance Office in organizing health insurance medical examinations and treatments in border areas according to guidelines issued by the Ministry of Health and the Ministry of Finance regarding health insurance medical examinations and treatments in border areas.

3. Cases of medical examinations and treatments on demand shall be reimbursed by the health insurance fund within the scope of rights and benefits as stipulated in:

a) Clause 1 Article 4 of this Decree for cases of medical examinations and treatments as stipulated in Articles 26, 27, and Article 28 of the Health Insurance Law and Clauses 4, 5, and 6 Article 22 amended and supplemented by the Health Insurance Law; patients shall pay out-of-pocket for costs exceeding the scope of rights and benefits;

b) Clause 3 Article 22 amended and supplemented by the Health Insurance Law for cases of self-initiated medical examinations and treatments outside the designated level; patients shall pay out-of-pocket for costs exceeding the scope of rights and benefits.

Article 5. Application of payment methods for medical examination and treatment costs according to Article 30, amended and supplemented by the Health Insurance Law.

1. The payment method based on fixed rates shall be applied to primary health insurance medical examination and treatment facilities.

2. Payment methods based on service fees and case-based payments shall be applied:

a) For medical examination and treatment facilities that do not implement the payment method based on fixed rates;

b) Payment for medical services outside the fixed rate at health insurance medical examination and treatment facilities implementing payment based on fixed rates;

c) Payment for medical examination and treatment costs for cases transferred to health insurance medical examination and treatment facilities implementing payment based on fixed rates.

3. The Ministry of Health shall take the lead and coordinate with the Ministry of Finance to provide detailed guidance and specifically apply the payment methods stipulated in Clause 1 and Clause 2 of this Article to medical examination and treatment facilities in accordance with their specific circumstances.

Chapter III

MANAGEMENT AND USE OF THE HEALTH INSURANCE FUND

Article 6. Allocation and use of the health insurance fund

The total health insurance revenue collected in provinces and centrally governed cities under the contribution levels prescribed in Article 2 of this Decree shall be allocated and used as follows:

1. Ninety percent of the health insurance contributions (hereinafter referred to as the medical examination and treatment fund) shall be used for the following purposes:

a) To pay for expenses within the scope of benefits for insured persons as prescribed in Article 22, amended and supplemented by the Health Insurance Law and Article 4 of this Decree.

b) To retain for educational institutions within the national education system that meet the conditions set forth by the Ministry of Health to purchase medicines, consumable medical supplies, medical equipment, and common medical tools to organize medical examinations and treatments in primary healthcare work for children, students, and trainees.

The amount retained for educational institutions within the national education system shall be equal to 7% of the total health insurance revenue calculated based on the total number of students and trainees currently enrolled in educational institutions participating in health insurance (including students and trainees participating in health insurance under other groups) and the corresponding contribution levels for each group as prescribed in Article 2 of this Decree; and 5% of the total health insurance revenue calculated based on the total number of children under six years old currently enrolled in preschool educational institutions.

In the first month of the academic year or course, the Social Insurance Organization shall be responsible for transferring the aforementioned amount to educational institutions and consolidating these funds into the settlement of health insurance medical examination and treatment costs within its management scope. Educational institutions receiving the funds shall be responsible for using them and settling accounts with higher-level management authorities in accordance with regulations.

c) To retain for agencies, organizations, and enterprises that have in-house medical facilities to carry out medical examinations and treatments in primary healthcare work for the subjects managed by such agencies, organizations, and enterprises (excluding agencies, organizations, and enterprises with in-house medical facilities that have signed primary health insurance medical examination and treatment contracts with the Social Insurance Organization). The retention amount shall be equal to 1% of the total health insurance contributions paid by agencies, organizations, and enterprises to the Social Insurance Organization.

The Ministry of Health and the Ministry of Finance shall provide detailed guidance on Points b and c of Clause 1 of this Article regarding conditions and scale of organization; content of expenditure; management and settlement of this source of funding.

2. Ten percent of the health insurance contributions shall be reserved for the reserve fund and administrative costs of the health insurance fund, including a minimum of 5% of the health insurance contributions reserved for the reserve fund and defined as follows:

a) The total annual administrative costs of the health insurance fund shall be decided by the General Director of the Vietnam Social Security within the total administrative costs of the Vietnam Social Security.

b) The reserve fund is the remaining portion after deducting the administrative costs of the health insurance fund.

3. The management and use of health insurance revenues shall be carried out as follows:

a) Social Insurance Organizations at all levels under the Vietnam Social Security shall directly collect health insurance contributions from the insured and transfer them to the Vietnam Social Security for management in accordance with the guidance of the Vietnam Social Security;

b) The Vietnam Social Security shall be responsible for timely transferring sufficient funds to provincial Social Insurance Organizations to temporarily advance and settle health insurance medical examination and treatment costs as prescribed.

4. Annually, based on the approved final settlement figures of the Vietnam Social Security Management Council, the unused portion of the funds allocated for medical examination and treatment in provinces and centrally governed cities where the health insurance revenue allocated for medical examination and treatment exceeds the medical examination and treatment expenditures in the year shall be used as follows:

a) The unused portion of the funds allocated for medical examination and treatment in 2014, the Vietnam Social Security shall be responsible for fully accounting it into the reserve fund;

b) From January 1, 2015 to December 31, 2020, the Vietnam Social Security shall be responsible for accounting 80% into the reserve fund, while notifying 20% of the unused funds allocated for medical examination and treatment to localities for implementation in accordance with Point a of Clause 3 of Article 35, amended and supplemented by the Health Insurance Law.

Based on the unused funds used locally, the Department of Health shall take the lead and coordinate with the Department of Finance and the provincial Social Insurance Organization to develop a usage plan to submit for approval by the Provincial People's Committee and report to the Provincial People's Council. Based on the decision of the Provincial People's Committee, the provincial Social Insurance Organization shall transfer funds to units for implementation.

Units allocated funds shall be responsible for managing and using them in accordance with current regulations and settling accounts with the provincial Social Insurance Organization to consolidate into the final settlement of the health insurance fund of the province to ensure the purpose, effectiveness, transparency, and clarity.

c) From January 1, 2021, the Vietnam Social Security shall be responsible for fully accounting the unused portion of the funds into the reserve fund for overall regulation.

Article 7. Management and use of the reserve fund

1. The reserve fund managed by the Vietnam Social Security shall be used to supplement the funding for health check-ups and treatments under health insurance for provinces and cities when the amount of health insurance revenue allocated for health check-ups and treatments according to Clause 1, Article 6 of this Decree is less than the expenditure on health check-ups and treatments in that year. After the annual settlement report is completed, the provincial or city-level Social Security shall report to the Vietnam Social Security for review to fully cover the difference from the reserve fund.

2. In cases where the reserve fund is insufficient to supplement the funding for health check-ups and treatments for provinces and cities as stipulated in Clause 1 of this Article, the Vietnam Social Security shall report to the Management Council of the Vietnam Social Security for a solution before reporting to the Ministry of Health and the Ministry of Finance.

The Ministry of Health shall take the lead and coordinate with the Ministry of Finance to submit measures to the Government to ensure sufficient and timely funding for health check-ups and treatments under health insurance as prescribed.

Article 8. Management costs of the health insurance fund

1. Regular expenses shall be implemented in accordance with the provisions of the law, including:

a) Special expenses include:

- Expenses for propaganda and coordination in the work of promoting health insurance;

- Expenses related to the tasks of collecting and disbursing funds of the health insurance fund;

- Expenses for coordination in the work of inspection, examination, and supervision of health insurance implementation.

b) Expenses for the operation of the social security machinery serving the management of the health insurance fund at all levels.

2. Irregular expenditures, including:

a) Expenses for the development and modernization of information technology;

b) Expenses for scientific research, training, enhancement, and international cooperation related to the field of health insurance.

3. Other tasks of expenses as prescribed by law.

The Ministry of Finance shall provide detailed guidance on the content and level of expenses prescribed in this Article.

Article 9. Investment activities from the health insurance fund

1. The temporarily idle funds of the health insurance fund shall be used for investment in forms prescribed by the Social Insurance Law.

2. The Management Council of the Vietnam Social Security shall decide and be responsible to the Government for the form and structure of the health insurance fund's investment based on the proposal of the Vietnam Social Security.

3. All profits actually received from the health insurance fund's investment activities each year shall be supplemented into the reserve fund for overall regulation.

Article 10. Settlement and preparation of financial plans

1. The Vietnam Social Security shall complete the annual settlement report before October 1st of the following year in accordance with Article 32, amended and supplemented by the Health Insurance Law.

2. Annually, the Vietnam Social Security shall prepare a financial plan regarding the collection and disbursement of the health insurance fund; management costs of the health insurance fund and investment from the temporarily idle funds of the health insurance fund, to be submitted to the Management Council of the Vietnam Social Security for approval and reported to the Ministry of Finance and the Ministry of Health.

The Ministry of Finance shall take the lead and coordinate with the Ministry of Health to examine and consolidate to submit to the Prime Minister for decision on the annual financial plan.

3. Within fifteen days from receiving the Decision on the budget estimate from the Prime Minister, the Vietnam Social Security shall be responsible for completing the allocation of the budget estimate for collection to units.

Chapter IV

IMPLEMENTING PROVISIONS

Article 11. Transitional Provisions

1. In cases where the person participating in health insurance has a health insurance card still valid after the date the Law amending and supplementing certain articles of the Health Insurance Law comes into effect, the scope of benefits and the level of enjoyment shall be implemented in accordance with the Law amending and supplementing certain articles of the Health Insurance Law and Article 4 of this Decree.

2. In cases where a person with a health insurance card is undergoing treatment at a medical facility but the health insurance card has expired, they will still be covered by the health insurance fund for health check-up and treatment costs within the scope of benefits and the level of enjoyment according to the regulations until discharge or completion of outpatient treatment.

3. A person who enters the hospital for treatment before January 1, 2015 but is discharged from the hospital starting from January 1, 2015 shall be covered by the health insurance fund for health check-up and treatment costs within the scope of benefits and the level of enjoyment as prescribed in the Law amending and supplementing certain articles of the Health Insurance Law and Article 4 of this Decree.

4. For the subjects specified in Point a, Clause 3, Article 12, amended and supplemented by the Health Insurance Law, when retiring, being discharged from military service, transferring to another profession, or quitting their job, the time spent studying and working in the People's Army, the Public Security Force, and the Cryptographic Organization shall be counted as the time they have participated in health insurance.

5. Students who have paid health insurance for the entire academic year 2014-2015 shall not need to make up the difference according to the health insurance contribution rate prescribed in Point g, Clause 1, Article 2 of this Decree.

6. For educational institutions belonging to the national education system that had transferred funds from the health check-up and treatment insurance fund to implement primary healthcare for students before January 1, 2015, they shall follow the guidance of the Ministry of Finance until the end of the 2014-2015 academic year.

Article 12. Effective Date

This Decree takes effect from January 1, 2015.

Decree No. 62/2009/NĐ-CP dated July 27, 2009 of the Government detailing and guiding the implementation of certain articles of the Health Insurance Law ceases to be effective from the date this Decree takes effect.

Article 13. Responsibilities for guidance on implementation

1. The Ministry of Health shall take the lead and coordinate with the Ministry of Finance to guide the implementation of the provisions assigned in this Decree; guide participation in health insurance under family registration and study and propose solutions to implement universal health insurance as stipulated in this Decree.

2. The Ministry of Finance shall be responsible for balancing and allocating the central budget to support localities that have not yet achieved self-balancing of their budgets to ensure the source for implementing the health insurance policy as prescribed in this Decree; guide the transfer of funds from the management costs of the health insurance fund to the People's Committees at the commune level to establish lists of participants in health insurance within their jurisdictions; guide the implementation of the provisions assigned in this Decree.

3. The Ministry of National Defense and the Ministry of Public Security shall take the lead and coordinate with the Ministry of Health and the Ministry of Finance to guide the implementation of health insurance for subjects as prescribed in Point a, Point 1, Point n Clause 3 and Point b Clause 4 Article 12 amended and supplemented in the Health Insurance Law.

4. The Vietnam Social Security shall be responsible for determining the cumulative monthly co-payment amount throughout the year as the basis for determining the benefit level of health insurance participants who have continuously participated in health insurance for five years or more.

5. The Ministry of Labor, Invalids and Social Affairs shall study and develop criteria for identifying households engaged in agriculture, forestry, fisheries, and salt production with a moderate standard of living to submit to the Prime Minister for issuance.

Guide the establishment of lists of individuals belonging to households engaged in agriculture, forestry, fisheries, and salt production with a moderate standard of living.

6. Other relevant ministries and sectors within the scope of their functions, tasks, and authorities shall be responsible for guiding the implementation of this Decree.

1. The Minister, Heads of Ministries equivalent to ministries, Heads of government agencies, Chairmen of provincial People's Committees under the central government, and related agencies, units, and individuals are responsible for implementing this Circular.

Ministers, Heads of ministerial-level agencies, Heads of agencies under the Government, Chairpersons of People's Committees of provinces and centrally governed cities are responsible for implementing this Decree.