Circular No. 15/2018/TT-BYT stipulates uniform prices for health insurance medical examination and treatment services among hospitals of the same level nationwide and provides guidance on applying prices and settling costs for medical examinations and treatments in certain cases.

CIRCULAR

Article on unifying the prices of medical examination and treatment services under health insurance between hospitals of the same level nationwide

  between hospitals of the same level throughout the country and guiding the application of prices and payment for examination and treatment costs in certain cases

Pursuant to the Law on Medical Examination and Treatment dated November 23, 2009;

Pursuant to the Price Law dated June 20, 2012;

Pursuant to the Law Amending and Supplementing Certain Provisions of the Health Insurance Law on June 13, 2014;

Pursuant to Decree No. 85/2012/NĐ-CP dated October 15, 2012 of the Government on the operational mechanism, financial mechanism for public health service units and prices of medical examination and treatment services provided by public medical establishments;

Pursuant to Decree No. 16/2015/NĐ-CP dated February 14, 2015 of the Government stipulating the self-management mechanism of public service units;

Pursuant to Decree No. 149/2016/NĐ-CP dated November 11, 2016 of the Government amending and supplementing some articles of Decree No. 177/2013/NĐ-CP dated November 14, 2013 of the Government detailing and guiding the implementation of certain provisions of the Law on Prices;;

Pursuant to Decree No. 75/2012/NĐ-CP dated June 20, 2017 of the Government stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;;

Based on the opinions of the Ministry of Finance at specialized agency under the People's Committee of the province/city.letter number 5834/BTC-QLG dated November 21 the 5 Article 2. The receipt, handling of reflections and petitions from individuals and organizations concerning administrative regulations shall be carried out in accordance with Decree No. 20/2008/NĐ-CP dated February 14, 2008 of the Government on the receipt, handling of reflections and petitions from individuals and organizations concerning administrative regulations (amended and supplemented by Decree No. 48/2013/NĐ-CP dated May 14, 2013 on amending and supplementing certain articles of decrees related to administrative procedure control and Decree No. 92/2017/NĐ-CP dated August 7, 2017 on amending and supplementing certain articles of decrees related to administrative procedure control).8;

The Minister of Health promulgates this Circular to unify the prices of medical examination and treatment services under health insurance between hospitals of the same level nationwide and guide the application of prices and payment for medical examination and treatment costs under health insurance in certain cases.

Article 1. Scope of Regulation and Applicability

1. This Circular unifies the prices of medical examination and treatment services under health insurance between hospitals of the same level nationwide and guides the application of prices and payment for medical examination and treatment costs under health insurance in certain specific cases.

2. This Circular applies to healthcare facilities, units, organizations, and individuals involved in the process of medical examination and treatment and payment and settlement of medical examination and treatment costs under the health insurance regime.

For medical examination and treatment services not reimbursable from the health insurance fund, the price framework and authority to set price levels shall be implemented according to the Law on Prices, the Law on Medical Examination and Treatment, the Law on Local Administration Organization, and guiding documents.

Article 2. Prices of medical examination and treatment services under health insurance

1. The prices of medical examination and consultation services are specified in Appendix I attached hereto;

2. The prices of hospital bed day services are specified in Appendix II attached hereto;

3. The prices of medical technical services are specified in Appendix III attached hereto.

4. Supplementary notes for some medical technical services that have been ranked equivalent by the Ministry of Health in the Decisions of the Ministry of Health are provided in Appendix IV attached hereto.

Article 4. Structure of Health Insurance Diagnostic and Treatment Service Prices

The prices of medical examination and treatment services prescribed in this Circular are established based on direct costs and salaries to ensure medical examination, care, and treatment of patients and the provision of medical technology services; specifically as follows:

1. Direct costs included in the medical examination price

a) Costs for clothing, hats, masks, sheets, pillows, mattresses, mats, office supplies, gloves, cotton, bandages, alcohol, gauze, saline solution, and other consumables used in diagnostic activities;

b) Costs related to electricity; water; fuel; waste management (solid, liquid); laundry, ironing, sterilization of textiles, examination tools; hygiene and environmental sanitation costs; disinfection chemicals and anti-infection materials during medical examinations;

c) Maintenance and repair costs for buildings, equipment, procurement and replacement of assets, tools, such as: air conditioners, computers, printers, dehumidifiers, fans, tables, chairs, beds, cabinets, lighting fixtures, other necessary tools and equipment during medical examinations.

2. Direct costs included in the medical examination bed-day service price

a) Costs related to clothing, hats, masks, quilts, sheets, pillows, mattresses, mosquito nets; office supplies; gloves used in examinations, injections, infusions, cotton, bandages, alcohol, gauze, saline solution, and other consumables serving daily care and treatment (including costs for changing dressings for inpatients, except in cases paid outside the bed day fee specified in Clause 5, Clause 6, Article 7 of this Circular); electrodes, ECG cables, blood pressure cuffs, SPO2 cables during patient monitoring in intensive care beds.

Specifically, costs related to medicines, blood, infusion fluids, materials (excluding those mentioned above); syringes, needles used in injections, infusions; infusion tubes, connectors, syringe pump cables, infusion machine cables used in injections, infusions; oxygen, oxygen tubing, oxygen masks (except in cases where patients are prescribed mechanical ventilation services) are not included in the bed cost structure and are paid based on actual usage.

b) Costs as stipulated in Point b and Point c, Clause 1 of this Article serving patient care and treatment according to professional requirements.

3. Direct costs included in the medical technical service price

a) Costs related to clothing, hats, masks, sheets, pillows, mattresses, mosquito nets, textile items; office supplies; medicines, infusion fluids, chemicals, consumables, replacement materials used in the provision of medical services and technologies;

b) Costs as stipulated in Point b and Point c, Clause 1 of this Article serving the provision of medical technical services according to professional requirements.

4. Salary costs included in the medical examination, bed-day, and medical technical service prices, including:

a) Salaries, rank-based allowances, contributions according to regulations by the State for public service units and the basic salary level stipulated in Decree No. 66/2013/NĐ-CP dated June 27, 2013 of the Government on the basic salary level for civil servants, public officials, employees, and military personnel;

b) On-call allowance, surgical and procedural allowance pursuant to Decision No. 73/2011/QĐ-TTg dated December 28, 2011 of the Prime Minister on special allowances for civil servants, public officials, and workers in public health institutions and anti-disease allowances;

5. Salary costs in the service prices stipulated in Clause 4 of this Article do not include expenses covered by the state budget as stipulated in the following documents:

a) Decree No. 64/2009/ND-CP dated July 30, 2009 of the Government on policies for medical staff working in areas with extremely difficult economic and social conditions;

b) Decree No. 116/2010/NĐ-CP dated December 24, 2010 of the Government on policies for cadres, civil servants, public officials, and personnel receiving salaries working in areas with extremely difficult economic and social conditions;

c) Decision No. 46/2009/QĐ-TTg dated March 31, 2009 of the Prime Minister on special allowances for cadres and public officials working at the Vietnam Friendship Hospital, Thong Nhat Hospital, Da Nang Central Hospital C under the Ministry of Health, Central Units 1, 2, 2B, 3, and 5, Department A11 of the 108 Military Central Hospital, and Department A11 of the Military Central Institute of Oriental Medicine (hereinafter referred to as Decision No. 46/2009/QĐ-TTg) and Decision No. 20/2015/QĐ-TTg dated June 18, 2015 of the Prime Minister on amending and supplementing certain articles of Decision No. 46/2009/QĐ-TTg;

d) Point a Clause 8 Article 6 Decree No. 204/2004/NĐ-CP dated December 14, 2004 of the Government on salary system for cadres, civil servants, public officials, and military personnel and Decree No. 76/2009/NĐ-CP dated September 15, 2009 of the Government on amending and supplementing certain articles of Decree No. 204/2004/NĐ-CP dated December 14, 2004 of the Government on salary system for cadres, civil servants, public officials, and military personnel.

6. The payment for medical examination and treatment costs between the health insurance agency and healthcare facilities according to the service prices stipulated in this Circular and drug, chemical, medical supplies costs not included in the service price (specifically noted in each service), blood and blood products shall be made in accordance with the provisions of Clause 3, Article 11 of the Joint Circular No. 41/2014/TTLT-BYT-BTC dated November 21, 2014 issued by the Ministry of Health and the Ministry of Finance guiding the implementation of health insurance.

7. The costs specified in Clauses 1, 2, 3, and 4 of this Article shall be determined based on economic and technical norms, cost standards issued by competent authorities, the prices of cost factors, actual cost levels, reasonably in accordance with current regulations and policies, ensuring average and advanced levels, meeting quality service requirements. Economic and technical norms serve as the basis for establishing medical examination and treatment service prices and shall not be used as grounds for payment for specific medical examination and treatment services (except for certain special cases stipulated in Clause 16, Article 6 and Clause 8, Article 7 of this Circular). During implementation, if there are unsuitable norms, units and localities shall report to the Ministry of Health for review and adjustment of norms and prices accordingly.

Article 4. Principles of Application service price for healthcare facilities that have signed contracts for medical examination and treatment under health insurance

1. Hospitals with beds, medical centers with functions of medical examination and treatment, licensed to operate as hospitals; district medical centers with functions of medical examination and treatment classified as hospitals: apply the price level of equivalent hospital grade.

2. Provincial or municipal administrative health protection clinics not directly affiliated with provincial or municipal general hospitals: shall apply the outpatient examination price level of Grade II hospitals.

3. Healthcare facilities not yet classified; military outpatient clinics, military-civilian outpatient clinics, military infirmaries, infirmaries; private general and specialized outpatient clinics: apply the price level of Grade IV hospitals.

4. Regional general outpatient clinics belonging to district medical centers or district-level hospitals after reorganization in accordance with the guidelines of the Ministry of Health:

a) In the case of being licensed to operate as a hospital or approved to convert into an inpatient department of a regional general hospital of the province, district hospital, or district medical center: apply the price level of Grade IV hospitals;

b) In the case of only performing emergency tasks, outpatient medical examination and treatment but having beds designated by the Department of Health: apply the price level of Grade IV hospitals. Specifically, the bed price applies at 50% of the price level of Grade III internal medicine ward days of Grade IV hospitals. The maximum number of days to be reimbursed is three days/person/treatment session. No reimbursement for outpatient examination fees when bed fees have been reimbursed at the commune health station.

5. Commune, ward, town health stations, health stations of agencies, units, organizations, schools, combined civilian-military health stations:

a) Outpatient examination fee: apply the price level of commune health stations. Technical service fees apply at 70% of the price level of Grade IV hospitals.

b) For commune health stations designated by the Department of Health to have beds: apply the price level at 50% of the price level of Grade III internal medicine ward days of Grade IV hospitals. The maximum number of days to be reimbursed is three days/person/treatment session. No reimbursement for outpatient examination fees when bed fees have been reimbursed at the commune health station.

Article 5. XDetermining the number of times, the price level and payment for outpatient examination in certain specific cases

1. In the case where a patient undergoes outpatient examination at the outpatient department and then is admitted for inpatient treatment according to professional requirements, it will still be counted as one outpatient examination. If the patient does not register for outpatient examination at the outpatient department but undergoes examination and is admitted for inpatient treatment at clinical departments according to professional requirements, it will not be counted as one outpatient examination.

2. Healthcare facilities organizing specialty outpatient clinics at clinical departments, patients registering for outpatient examination at the outpatient department and specialty examination at clinical departments shall be considered as outpatient examination at the outpatient department. The calculation of the number of outpatient examinations and the price level shall be implemented in accordance with the provisions of Clause 3 of this Article.

3. In the same visit for outpatient examination at the same healthcare facility (which may be on the same day or due to objective conditions or professional requirements, the outpatient examination process cannot be completed on the first day and must continue on the following day), if the patient needs to see additional specialties after seeing one specialty, from the second visit onwards, only 30% of the price level of one outpatient examination will be charged, and the maximum reimbursement for outpatient examination costs for that person will not exceed twice the price level of one outpatient examination.

4. Patients who come for outpatient examination at a healthcare facility, have already undergone examination and been prescribed medication for home treatment, but later show abnormal symptoms and return to the same healthcare facility for immediate re-examination on the same day and continue to be examined, this visit will be considered as the second visit onwards in one day. Payment will be made in accordance with the provisions of Clause 3 of this Article;

5. A patient who comes to a multi-disciplinary health center for outpatient examination and is then referred to a hospital or district health center for further examination shall be considered as a new outpatient examination.

6. Healthcare facilities must coordinate and arrange manpower and examination tables according to requirements to ensure the quality of outpatient examination. For examination tables with more than 65 visits/day: the social insurance agency will only reimburse 50% of the outpatient examination fee from the 66th visit onwards of that examination table. Within a maximum period of one quarter, if the healthcare facility still has examination tables with more than 65 visits/day, the social insurance agency will not reimburse the outpatient examination fee from the 66th visit onwards of that examination table.

Article 6. Determining the number of days for bed occupancy, applying the price level, and settling the bed day fee between the social insurance agency and healthcare facilities.

1. Determining the number of inpatient treatment days for bed fee reimbursement:

a) The number of inpatient treatment days equals the discharge date minus (-) the admission date: applicable to cases where the patient is discharged after recovery or cure.

b) The number of inpatient treatment days equals the discharge date minus (-) the admission date plus (+) 1: applicable to cases:

- A seriously ill patient undergoing inpatient treatment whose condition has not improved or worsened, but the family requests to go home or transfer to a higher-level facility;

- A patient who has been treated at a higher-level facility through the emergency phase but still requires continued inpatient treatment and is transferred back to a lower-level facility or to another healthcare facility.

c) In the case where a patient is admitted and discharged on the same day, with treatment time exceeding four hours, it will be counted as one day of inpatient treatment. Specifically, for patients admitted to the emergency department without going through the outpatient department, with emergency treatment and treatment time less than four hours (including cases of discharge, admission, or transfer, death), outpatient examination fees, drug fees, medical supply fees, and technical service fees will be reimbursed, but no bed fee for intensive care emergency will be reimbursed.

2. In case a patient transfers between two departments on the same day, each department shall only be counted as half a day. If a patient transfers among three or more departments on the same day, the bed price for that day shall be calculated based on the average of the highest and lowest bed prices at departments where the patient stays more than four hours.

3. The post-operative bed price for surgical and burn wards shall apply for a maximum of ten days after surgery. From the eleventh day onwards, the bed price for internal medicine wards as specified in Section 3 of Appendix II accompanying this Circular shall apply.

4. The bed price is calculated for one person per bed. In cases where two people share one bed simultaneously, payment shall be made at half the rate, and for three or more people sharing a bed, payment shall be made at one-third of the rate for the corresponding treatment bed.

5. The daily bed rate for Intensive Care Unit (ICU) treatment can only be applied in the following cases:

a) For special-class, Class I, or Class II hospitals that have established Intensive Care Units (ICU), Poison Control Departments, ICU-Poison Control Departments, and these departments meet all conditions for operation as stipulated in Decision No. 01/2008/QD-BYT dated January 21, 2008, issued by the Minister of Health regarding emergency care, intensive care, and poison control (hereinafter referred to as Decision No. 01/2008/QD-BYT).

b) In cases where healthcare facilities have not established ICUs but have some beds in the Emergency Department or Anesthesia Recovery Department used for intensive treatment, postoperative beds for special surgeries, and these beds meet the requirements for ICU beds as stipulated in Decision No. 01/2008/QD-BYT.

c) Patients staying in these beds must receive care, treatment, and monitoring according to the emergency care, intensive care, and poison control regulations. Other cases shall only apply the price for emergency ICU beds and other types of beds as specified in Appendix II accompanying this Circular.

6. For clinical departments with emergency ICU beds (for example, pediatric departments with pediatric emergency ICU beds, neonatal departments, or specialized care for premature infants): the price for emergency ICU beds as specified in service number 2 of Appendix II accompanying this Circular shall apply.

7. For Class III, Class IV hospitals, or unranked hospitals approved by competent authorities to perform special surgeries: the highest post-operative bed price for surgical wards of the hospital providing the service shall apply.

Example: At Hospital A, which has been approved to perform special surgeries: if the hospital is ranked Class III, it shall apply the post-operative bed price for Class I surgical wards of Class III hospitals; if the hospital is ranked Class IV or unranked, it shall apply the post-operative bed price for Class I surgical wards of Class IV hospitals.

8. In cases where a surgery is classified differently across various specialties (excluding pediatrics) as specified in Circular No. 50/2014/TT-BYT dated December 26, 2014, issued by the Minister of Health regarding the classification of surgeries, procedures, and staffing levels for each surgery and procedure (hereinafter referred to as Circular No. 50): the bed price for surgical and burn wards shall apply based on the lowest surgery classification.

9. Surgeries classified by the Ministry of Health as equivalent to those specified in this Circular but classified differently across specialties as specified in Circular No. 50: the bed price for surgical and burn wards shall apply based on the classification of the surgery as specified in Circular No. 50.

10. For surgeries not classified according to the provisions of Circular No. 50, the price level for surgical ward bed day type 4 corresponding to the hospital category shall be applied.

11. For Class I Traditional Medicine Hospitals under the Ministry of Health: the bed price shall apply according to the corresponding departments and bed types of Class I hospitals, without applying the prices of specialized hospitals under the Ministry of Health in Hanoi and Ho Chi Minh City.

12. For departments within Traditional Medicine Hospitals (excluding those specified in Clause 11 of this Article) and rehabilitation hospitals:

a) Intensive Care Unit (ICU) beds: as provided for in Clause 5 of this Article;

b) Emergency ICU Bed: as stipulated in Clause 6 of this Article;

c) Patients treated in oncology and pediatric departments: the price for internal ward bed day type 1 shall be applied;

d) Patients treated for spinal cord injury, cerebrovascular accident, or brain trauma: the price for internal ward bed day type 2 shall be applied;

đ) Patients treated in other departments: the price for internal ward bed day type 3 shall be applied.

13. For healthcare facilities organizing departments in a multi-specialty format: the price for internal ward bed day of the lowest specialty among the corresponding departments shall be applied according to the hospital category.

14. Only in cases of overcapacity may healthcare facilities add extra beds beyond the planned quota to serve patients and be included in the settlement with social insurance agencies as stipulated in Clause 16 of this Article.

15. In cases where patients lie on stretchers or folding beds: the price shall be applied at fifty percent of the bed price for the respective specialty as specified in Appendix II accompanying this Circular.

16. The quarterly settlement of daily bed fees between the social insurance agency and healthcare facilities shall be carried out as follows:

a) Actual bed usage in a quarter (year) = Total number of inpatient treatment days in the quarter (year) divided by the actual number of days in the quarter (year is 365 days), where inpatient treatment days are converted according to the principle: stretcher beds, folding beds, two-person shared beds: two converted bed days equal one bed day; three-person or more shared beds: three converted bed days equal one bed day.

b) In cases where the actual number of beds used in the quarter is lower than or equal to 120% of the allocated bed plan: pay 100% of the total amount based on the actual number of bed days and the prescribed rates.

c) In cases where the actual number of beds used exceeds 120% of the allocated bed plan in a year, the healthcare facility and the social insurance agency shall determine and agree on the payment method as follows:

- Calculate the actual bed utilization ratio per quarter (hereinafter referred to as the bed utilization ratio) by dividing the actual bed usage of the quarter by the actual bed usage in 2015 (the year before the network was established) multiplied by one hundred percent. In cases where the actual bed utilization ratio is calculated as above:

+ Is less than or equal to 130%: the health insurance agency pays the healthcare facility 100% of the total amount based on the actual number of bed days and the prescribed rates;

+ Exceeds 130% but does not exceed 140%: the health insurance agency pays the healthcare facility 97% of the total amount based on the actual number of bed days and the prescribed rates;

+ Exceeds 140% but does not exceed 150%: the health insurance agency pays the healthcare facility 95% of the total amount based on the actual number of bed days and the prescribed rates;

+ Exceeds 150%: the health insurance agency pays the healthcare facility 90% of the total amount based on the actual number of bed days and the prescribed rates.

d) In cases where healthcare facilities are consistently overloaded due to objective reasons such as expansion of administrative boundaries, increase in health insurance registration cards: the Department of Health shall report to the provincial People's Committee for consideration and allocation of additional beds and staff positions to ensure the quality of medical services.

đ) In cases where healthcare facilities put new construction projects, renovation, expansion, upgrade, or newly built facilities into use but have not been allocated additional beds by competent authorities: the Department of Health and the social insurance agency shall agree on the additional beds in this area to be added to the previously allocated planned beds to implement settlements as stipulated in this clause.

Article 7. Other protection scopesapply price and conditions, payment levels of certain services special techniques

1. Medical technical services shall be applied in the following order:

a) For specific services already defined with prices in the appendices issued along with this Circular: apply the defined prices.

b) Technical services not specified with prices in the appendices issued together with this Circular but have been classified equivalently in terms of technical level and implementation costs: apply the prices of the technical services classified equivalently by the Ministry of Health in terms of technical level and implementation costs.

c) In cases where there is overlap between different specialties, the technical service performed in a particular specialty shall be applied at the price of the technical service in that specialty.

2. For new technical services prescribed in Clause 1 and Clause 2, Article 69 of the Law on Medical Examination and Treatment and other remaining technical services (excluding those already classified equivalently by the Ministry of Health in terms of technical level and implementation costs) which have not been specified with prices: healthcare facilities shall establish cost standards, pricing schemes, propose price levels, and report to the Ministry of Health for consideration and determination of price levels.

3. For technical services that have been approved by competent authorities (Ministries and central agencies for units under central management, Provincial Health Departments for units under local management) in their service catalogues (excluding services included in the daily bed charge, and services that are part of another service's process): if such technical services are ordered but cannot be performed due to patient condition or disease progression: payment shall be made based on the actual quantity of medicines and materials used for the patient at the purchase price stipulated by law.

4. In cases where multiple interventions are performed during a single surgery: payment shall be made according to the highest-priced complex surgery, and other technical services arising outside the surgical procedure shall be paid as follows:

a) At 50% of the price of additional surgeries if the same surgical team performs them;

b) At 80% of the price of additional surgeries if a different surgical team is required;

c) In cases where the additional service is a procedure, reimbursement shall be made at 80% of the price of the additional service.

5. For the service "Changing wound dressing or incision bandage length ≤15 cm": payment shall only be made for inpatient patients in the following cases: infected wounds or incisions; wounds with fluid or blood leakage in skin avulsion injuries or exposed skin areas larger than 6 cm; wounds with gauze packing; leg wounds with drainage tubes leaking fluid; multiple wounds or incisions; or after one surgery but requiring two or more incisions; this does not apply to changing bandages for endoscopic surgeries, routine wound dressings, newborn umbilical cord care.²; the wound has been packed with gauze; the drainage from the wound on the limb is excessive; multiple wounds or surgical incisions; or after surgery but requires two incisions or more; this does not apply to bandaging in the following cases: laparoscopic surgery, changing the dressing of surgical incisions, routine wounds, and newborn umbilical cord care.

6. For the service "Changing bandages for surgical incisions longer than 15 cm to 30 cm" in inpatient treatment, it shall only be applied in the following cases:

a) Infected incisions, gastrointestinal fistulas, bile fistulas, urinary fistulas;

b) Incisions after contaminated surgery (peritonitis or osteomyelitis or abscess), incisions after digestive tract, urinary system, bile duct, or abdominal ascites surgery;

c) Incisions after surgery requiring two or more incisions;

d) In cases of cesarean section surgery: apply this price but not more than three times.

7. For immunohematology tests conducted at 37°C using anti-globulin serum (indirect Coombs test) in blood transfusions: payment shall be made according to the price of the "Immunohematology reaction using human anti-globulin" service with code 1340 or 1341 in Appendix III.

8. The settlement of certain technical services such as: Routine X-ray, Digital Radiography (for diagnosis), CT Scan up to 32 slices (for diagnosis, service codes 42, 43 in Appendix III), Ultrasound (service codes 1, 2 in Appendix III), Magnetic Resonance Imaging (MRI), service codes 67, 68 in Appendix III, shall be carried out quarterly between health insurance agencies and healthcare facilities as follows:

a) Determine the maximum number of cases payable by the social health insurance agency according to the price set forth in this Circular by equaling (=) the average number of cases according to the pricing standard divided (:) by 8, multiply (X) this result by the actual working hours of the unit, then multiply (X) by the actual number of working days in the quarter, multiply (X) by the actual number of machines in operation at the healthcare facility in the quarter, and finally multiply (X) by 120%.

b) Pricing standard (number of cases per machine per 8-hour working day): Ultrasound service is 48 cases; Routine X-ray, Digital Radiography is 58 cases; CT Scan up to 32 slices is 29 cases; Magnetic Resonance Imaging (MRI) is 19 cases.

c) In case the number of cases proposed for reimbursement is less than or equal to the maximum number of cases calculated under point a of this clause: the social insurance agency will reimburse according to the actual number of cases and the price set forth in this Circular.

d) In case the number of cases proposed for payment exceeds the maximum number calculated according to point a of this clause: for the number of cases equal to the maximum number calculated according to point a of this clause, the social health insurance agency shall pay according to the price set forth in this Circular. For the number of cases exceeding the maximum number calculated according to point a of this clause, the social health insurance agency shall pay according to the price excluding salary costs, specifically as follows:

- Diagnostic Ultrasound Service: 55% of the prescribed price.

- Routine X-ray; Digital Radiography: 85% of the prescribed price.

- Computed Tomography up to 32 slices Service: 95% of the prescribed price.

- Magnetic Resonance Imaging (MRI) service: 97% of the prescribed price.

Example: Healthcare Facility A has 3 active X-ray machines, actual working hours are 9 hours (1 extra hour per day); the facility operates outpatient clinics on Saturdays, in Quarter III/2018 there were 92 days, with 78 working days.

The maximum number of cases that the health insurance agency will pay according to the X-ray price specified in this Circular is: (58:8) X 9 X 3 X 78 X 120% = 18,322.2 cases.

If the total number of X-ray cases proposed for payment by the facility in the third quarter of 2018 is less than or equal to 18,322 cases, it will be paid according to the price specified in this Circular.

If the number of cases proposed for payment by the healthcare facility exceeds 18,322 cases, for example 20,000 cases, the health insurance agency shall pay 18,322 cases according to the price set forth in this Circular; the remaining 1,678 cases (=20,000 cases - 18,322 cases) shall be paid by the health insurance agency at 85% of the price set forth in this Circular.

9. The provisions in Clause 8, Article 7 and Clause 16, Article 6 of this Circular shall only apply for payment between the social health insurance agency and healthcare facilities, and shall not be applied to calculate the co-payment amount for patients.

10. During natural disasters or epidemics: the social health insurance agency shall pay healthcare facilities according to the actual price and quantity of services provided, without applying the payment regulations in Clause 8 of this Article and Clause 16, Article 6 of this Circular.

Article 8. State budget guarantee for costs not included in the price of medical examination and treatment services

1. Ministries and central agencies shall aggregate and report to the Ministry of Finance; Provincial Health Departments shall aggregate and report to the People's Committees of provinces to continue ensuring the budget according to the current budget classification and regulations on sources for implementing salary reform policies for:

a) Expenses according to the regulations stipulated in the documents mentioned in Clause 5 of Article 3 of this Circular.

b) State budget funds to ensure the implementation of salary reform policies according to current regulations and the base salary stipulated in Decree No. 66/2013/NĐ-CP dated June 27, 2013 of the Government regarding the base salary for civil servants, public officials, and armed forces personnel.

2. In cases where the revenue of the unit does not guarantee regular operations, and the unit is classified by the competent authority as a public institution self-financing part of its regular expenses or a public institution fully funded by the state for regular expenses: the unit shall continue to receive state budget funding for the shortfall in regular expenses to ensure employee benefits and normal operations according to the current budget management classification.

Article 9. Implementation Organization

1. Responsibilities of the Ministry of Health:

a) Department of Planning and Finance:

- Serve as the central point to coordinate with relevant departments and bureaus under the Ministry of Finance to examine, adjust, and promptly supplement the prices of medical examination and treatment services when new factors forming the price are added according to the schedule, when state policies on salaries are adjusted, or when economic-technical norms or costs of price-forming factors change.

- Serve as the contact point, coordinating with related units to organize the implementation, inspection, interim summary, and overall assessment of the implementation of this Circular nationwide.

b) The Department of Medical Examination and Treatment shall serve as the central point, coordinating with relevant departments, bureaus, and units to direct healthcare facilities to strictly implement professional regulations, comprehensively implement measures to improve service quality; organize inspections, audits, and supervision related to the prescription of services, medicines, materials, and inpatient admissions, as well as other professional activities.

c) The Health Insurance Department shall serve as the central point, coordinating with relevant departments, bureaus, the Ministry's Inspectorate, and related units to organize inspections, supervision, or direct provincial health departments and health management agencies of ministries and sectors to conduct inspections and supervision of healthcare facilities and related organizations in implementing the provisions of this Circular.

d) The Inspectorate of the Ministry of Health shall take the lead, coordinating with relevant departments, bureaus, and units to organize inspections or direct provincial health departments and health management agencies of ministries and sectors to conduct inspections of healthcare facilities and related organizations in implementing the provisions of this Circular.

2. Responsibilities of the Vietnam Social Security:

a) Implement this Circular, directing social insurance agencies at all levels to make timely payments according to current regulations and this Circular for healthcare facilities. If inappropriate pricing levels are discovered during implementation, submit a written request to the Ministry of Health for review and adjustment.

b) Regularly (monthly, quarterly, semi-annually, and annually) report to the Ministry of Health and direct social insurance agencies at all levels to inform provincial people's committees, municipal people's committees, provincial health departments, and health management agencies of ministries and sectors about cases where services, medicines, and materials are used excessively or patients are improperly admitted for inpatient care beyond necessary levels.

3. Responsibilities of the Health Departments:

a) Take the lead and coordinate with relevant units to organize the implementation, inspection, supervision, interim review, and final summary of this Circular within their jurisdiction.

b) Direct healthcare facilities under local management to strictly implement professional regulations, and to comprehensively implement measures to improve service quality.

c) Report to the competent authority to allocate hospital beds and determine the number of staff for healthcare facilities under local management to ensure these facilities have sufficient beds and personnel to meet needs and enhance the quality of medical examination and treatment services for the public.

4. Responsibilities of healthcare facilities:

a) Must use funds equivalent to maintenance and repair costs for equipment, replacement tools, and instruments already included in the service examination and treatment fee, daily bed charge (for special-class, class I, and class II hospitals, equivalent to 5% of the fee; for class III and class IV hospitals, equivalent to 3% of the fee) to repair, upgrade, and expand examination areas and treatment departments; purchase and replace: tables, chairs, beds, cabinets, trolleys, air conditioners, fans, heating lamps, electric heaters, computers, multi-specialty examination kits; quilts, sheets, pillows, mattresses, mats; etc., to ensure professional conditions, hygiene, patient safety, and improve service quality.

b) Strictly implement medical professional regulations, particularly regarding the referral of patients for inpatient treatment; transfer to higher-level facilities, and the prescription of services, medications, and supplies in accordance with regulations.

Article 10. Reference Provisions

In case the referenced documents in this Circular are replaced or amended, they shall be implemented according to the replacement document or the amended document.

Article 11. Implementation Provisions

1. This Circular takes effect from July 15, 2018.

2. Circular Jointly Issued No. 37/2015/TTLT-BYT-BTC dated October 29, 2015, by the Ministry of Health and the Ministry of Finance, which unified the prices of medical examination and treatment services under health insurance between hospitals of the same level nationwide and related implementation guidance documents, cease to be effective from July 15, 2018.

Article 12. Transitional Provisions

For patients undergoing treatment at healthcare facilities before the implementation date of the pricing regulations stipulated in this Circular and who are discharged or conclude their outpatient treatment period after that date: continue to apply the pricing levels prescribed by the competent authority prior to the implementation date of the pricing regulations stipulated in this Circular until discharge or conclusion of the outpatient treatment period.

In the course of implementation, if there are difficulties or obstacles, units and localities are requested to report in writing to the Ministry of Health for consideration and resolution./.