Circular No. 17/1998/TT-BYT guiding the implementation of medical examination and treatment, the use of the medical examination and treatment fund, and the payment of medical examination and treatment costs under health insurance.

CIRCULAR

DECREE NO. 17/1998/TT-BYT OF DECEMBER 19, 1998 OF THE MINISTRY OF HEALTH GUIDING THE IMPLEMENTATION OF MEDICAL EXAMINATION AND TREATMENT, USE OF THE MEDICAL EXAMINATION AND TREATMENT FUND, AND PAYMENT OF MEDICAL EXAMINATION AND TREATMENT COSTS UNDER COMPULSORY HEALTH INSURANCE

To implement the Health Insurance Charter issued pursuant to Decree No. 58/1998/NĐ-CP dated August 13, 1998 of the Government, the Ministry of Health guides in detail the implementation of medical examination and treatment, use of the medical examination and treatment fund, and payment of medical examination and treatment costs under compulsory health insurance as follows:

A. GUIDELINES FOR THE IMPLEMENTATION OF MEDICAL EXAMINATION AND TREATMENT
HEALTH INSURANCE

I. FOR HOLDERS OF HEALTH INSURANCE CARDS

1. Benefits for holders of health insurance cards

a) Holders of health insurance cards who go for outpatient medical examination and treatment, and inpatient treatment shall be entitled to:

- Medical examination and laboratory tests, X-ray examinations, functional diagnostic procedures as prescribed by the treating physician for diagnosis and treatment.

- Medicines within the list prescribed by the Ministry of Health; blood transfusions and intravenous infusions as prescribed by the treating physician; use of common consumable medical supplies and medical equipment for medical examination and treatment.

- Performing minor surgical procedures and surgeries.

- Using hospital beds.

b) Holders of health insurance cards may choose one of the initial medical examination and treatment facilities (medical examination and treatment facilities) convenient at their place of residence or workplace according to the guidance of the health insurance agency for health management and care, and medical examination and treatment. The initial medical examination and treatment facility is recorded on the health insurance medical examination and treatment card by the health insurance agency.

Initial medical examination and treatment registration location is a healthcare facility contracted by the health insurance agency to provide outpatient examination and treatment services for holders of health insurance cards, including: multi-specialty clinics of hospitals or health stations, multi-specialty clinics in districts, health clinics of health protection agencies for officials, health stations in communes, wards, towns, health stations of organizations or enterprises.

Holders of health insurance cards may request the health insurance agency to change their initial medical examination and treatment registration location at the end of each quarter.

c) In cases of emergency, holders of health insurance cards can be treated at any state healthcare facility and enjoy health insurance benefits.

d) When the patient's condition exceeds the expertise of the medical examination and treatment facility, the patient will be transferred to another level of treatment according to the regulations of the Ministry of Health.

e) For maternity: holders of health insurance cards register for antenatal care and delivery at healthcare facilities belonging to district, urban district, town, provincial city centers; if the condition exceeds the expertise of the registered facility, the patient will be transferred to another level of treatment according to the regulations of the Ministry of Health;

Holders of health insurance cards who comply with the above regulations will have their hospital fees reimbursed under health insurance when giving birth to the first and second child.

f) For social diseases: holders of health insurance cards who treat tuberculosis, malaria, schizophrenia, epilepsy will have their medical examination and treatment costs reimbursed by the health insurance agency, except for the cost of specialized drugs already provided by the state budget.

g) For household accidents: holders of health insurance cards will have their hospital fees reimbursed under health insurance.

h) Holders of health insurance cards will enjoy health insurance benefits when using rehabilitation services listed by the Ministry of Health.

i) Holders of health insurance cards have the right to lodge complaints with competent state authorities when employers, health insurance agencies, and medical examination and treatment facilities fail to ensure health insurance benefits.

2. Responsibilities of holders of health insurance cards when seeking medical examination and treatment

a) Present the health insurance card with photo or valid identification with photo and the health insurance medical examination and treatment card still valid when coming for medical examination and treatment at the registered medical examination and treatment facility or the facility where the patient is admitted for emergency treatment.

b) Present the health insurance card and health insurance medical examination and treatment card as stipulated in paragraph a above and the referral letter from the healthcare facility when the patient is referred to another healthcare facility for medical examination and treatment according to the technical specialty level specified by the Ministry of Health.

3. Payment of medical examination and treatment costs for holders of health insurance cards

a) Holders of health insurance cards who comply with the provisions at point 2, section I, part A of this Circular (medical examination and treatment according to the technical specialty level) will have their medical examination and treatment costs reimbursed by the health insurance agency at the current hospital fee rate, based on the principle of shared payment as follows:

* The health insurance agency will cover 100% of the costs of outpatient medical examination and treatment for persons with meritorious service to the revolution as defined in Joint Circular No. 15/1998/TTLT-BYT-BTC-BLĐTBXH dated December 5, 1998 of the Ministry of Health - Ministry of Finance - Ministry of Labor, Invalids and Social Affairs.

* The health insurance agency will reimburse 80% of the medical examination and treatment costs of patients not included in the category of persons with meritorious service to the revolution, the remaining 20% will be paid by the patient to the medical examination and treatment facility. When the amount that the patient pays for medical services under health insurance in a year exceeds six months' minimum wage, the health insurance agency will reimburse all subsequent medical examination and treatment costs in the year under health insurance.

Patients need to retain all valid receipts (such as hospital fee invoices as prescribed by the Ministry of Finance, discharge certificates) of the portion they pay themselves to the medical facility in a year to request reimbursement from the health insurance agency when the self-payment exceeds six months' minimum wage.

If the holder of a health insurance card presents the card late when seeking medical examination and treatment (except in cases of emergency, coma, etc.), they will only enjoy health insurance benefits at the medical examination and treatment facility from the day the health insurance card is presented. The patient must pay the medical examination and treatment costs before presenting the health insurance card to the medical examination and treatment facility and will be reimbursed by the health insurance agency as in the case of individual requests for medical examination and treatment.

b) Holders of health insurance cards will only have partial reimbursement of medical examination and treatment costs in the following cases:

- Choosing doctors, wards, and medical services on their own;

- Seeking medical examination and treatment at healthcare facilities not according to the initial registration for medical examination and treatment or at facilities that have not signed contracts with health insurance authorities unless it is an emergency case or there is a valid referral from a specialized technical level as prescribed by the Ministry of Health.

In the cases of seeking medical examination and treatment as mentioned above, patients shall bear all costs themselves and retain all legitimate receipts (prescriptions, medical records, purchase invoices for medicines, discharge certificates, payment receipts for hospital fees as stipulated by the Ministry of Finance, and other relevant documents) as the basis for requesting partial reimbursement from the health insurance authority as provided in Point 2, Section II, Part C of this Circular.

c) Holders of health insurance cards shall not be reimbursed by the health insurance authority for medical examination and treatment expenses in the following situations:

- Treating leprosy;

- Using special drugs (as listed by the Ministry of Health) funded by the state budget for treating diseases such as tuberculosis, malaria, schizophrenia, epilepsy;

- Family planning services, including: taking contraceptive pills, inserting intrauterine devices, performing abortions, male sterilization, female sterilization, and other contraceptive methods;

- Preventing and treating rabies;

- Preventing, testing, diagnosing, and treating HIV/AIDS, gonorrhea, syphilis;

- Costs for prenatal care and delivery of the third child onwards;

- Vaccination, convalescence, rehabilitation, health check-ups (such as regular health check-ups, pre-employment health examinations...);

- Cosmetic surgery and reconstructive surgery, glasses, hearing aids, artificial limbs, dentures, artificial joints, artificial lenses, artificial heart valves;

- Rehabilitation treatments outside the list prescribed by the Ministry of Health;

- Congenital diseases and congenital malformations;

- Occupational diseases;

- Work-related accidents (accidents during working hours at the workplace, including overtime work required by the employer; accidents outside working hours when performing tasks requested by the employer; accidents on the route between home and workplace);

- Traffic accidents, including residual effects of traffic accidents;

- War-related accidents;

- Accidents caused by natural disasters;

- Suicide, intentional injury, drug addiction, criminal offenses;

- Early pregnancy diagnosis tests, infertility treatments, purchasing medicines based on individual patient requests, transporting patients, using drugs and treatment methods in clinical trials, drugs outside the list prescribed by the Ministry of Health, and donated medicines.

II. FOR HEALTHCARE FACILITIES

1. Contracts for medical examination and treatment with health insurance authorities

Healthcare facilities are responsible for signing contracts with health insurance authorities to provide medical examination and treatment services and ensure the rights of health insurance card holders in accordance with the provisions of the Health Insurance Regulations and this Circular.

2. Organizing reception and guiding health insurance card holders to seek medical examination and treatment.

a. Cooperating with health insurance authorities to check and manage health insurance cards, medical examination and treatment vouchers, and referral letters (if the patient is a transferred patient) immediately upon the patient's arrival for medical examination and treatment.

b. Referring patients to seek medical examination and treatment at the appropriate specialized technical level as prescribed by the Ministry of Health.

c. During the inpatient treatment period, hospitals manage the patients' health insurance cards and return them to the patients upon discharge or transfer. If the patient dies in the hospital, the hospital is responsible for retaining the card to return to the health insurance authority.

3. Providing medical examination and treatment services to patients holding health insurance cards.

a. Conducting medical examination and treatment activities, ordering safe and reasonable laboratory tests and technical services in accordance with professional regulations.

b. Prescribing and distributing medications within the list prescribed by the Ministry of Health, not issuing prescriptions for patients to purchase their own medications, and if prescribing medications based on patient requests, clearly stating "at the patient's request."

c. Ensuring adequate supply of medications, blood, intravenous fluids, chemicals, laboratory tests, X-rays, contrast agents, and essential medical supplies for patients. The hospital pharmacy ensures timely and sufficient supply of medications in accordance with current regulations of the Ministry of Health.

d. When receiving patients referred from lower-level facilities, if inpatient treatment is not necessary, higher-level healthcare facilities are responsible for providing outpatient medications or directing treatment and transferring patients back to lower-level facilities for treatment, without issuing prescriptions for patients to purchase their own medications.

e. Healthcare facilities should facilitate conditions for health insurance authority staff stationed at the facility to perform appraisal, propaganda, and explanation regarding health insurance benefits; inspecting the protection of patients' rights under health insurance; resolving complaints related to health insurance medical examination and treatment; reviewing medical records and relevant documents related to health insurance medical examination and treatment.

f. Healthcare facilities are responsible for recording and preparing cost statements for health insurance medical examination and treatment promptly according to the model of the Vietnam Health Insurance.

g. Healthcare facilities are responsible for organizing and monitoring health insurance medical examination and treatment activities, and the billing department is responsible for tracking, statistics, and collecting self-pay portions of hospital fees from health insurance card holders. Healthcare facilities issue payment receipts in accordance with the Ministry of Finance regulations to patients.

Provincial Departments of Health and Health Departments of various sectors are responsible for directing subordinate healthcare facilities to provide medical examination and treatment services and ensure the rights of patients holding health insurance cards, while also strengthening measures to prevent abuse of health insurance funds, reasonable and safe prescription of laboratory tests and technical services, and rational, safe, effective, and economical use of medications.

The Department of Health is responsible for handling violations by subordinate healthcare facilities in providing medical examination and treatment services to patients holding health insurance cards within its jurisdiction.

III. FOR HEALTH INSURANCE AUTHORITIES

1. Guiding health insurance card holders to choose convenient initial registration healthcare facilities.

2. Signing contracts and coordinating with legal healthcare facilities to implement medical examination and treatment services for health insurance card holders in accordance with the contracts.

3. Provide forms and guide healthcare facilities to record and statistically report medical examination and treatment costs for patients with health insurance cards.

4. Supply data on registered health insurance cards and determine outpatient and inpatient funds for healthcare facilities.

5. Coordinate with healthcare facilities to check necessary documents that health insurance card holders must present when seeking medical services and resolve complaints related to the rights of health insurance card holders during medical examinations and treatments.

6. Review medical records, case files, and relevant materials concerning medical examinations, treatments, and payments made by patients at healthcare facilities to assess and inspect in order to ensure benefits for insured patients and have grounds for settlement with healthcare facilities.

7. Refuse payment for medical examination and treatment costs that do not comply with the Health Insurance Regulations and this Circular's provisions or do not conform to the terms stipulated in the health insurance medical examination and treatment contracts between the health insurance agency and healthcare facilities; detect cases of health insurance card abuse and misuse of the health insurance fund and handle them within their authority.

8. Process and settle medical examination and treatment costs for patients with health insurance cards with healthcare facilities according to regulations and within the prescribed period.

9. Guide and directly pay patients at the health insurance agency promptly and in accordance with regulations.

The provincial health insurance agency periodically (quarterly or after each settlement period) reports to the Department of Health on the situation of using the medical examination and treatment fund in the locality, evaluates the protection of the rights of health insurance card holders when seeking medical services at healthcare facilities in the province, proposes measures to protect patient rights, prevent misuse of the health insurance fund, and balance the medical examination and treatment health insurance fund in the locality.

B. USE OF THE HEALTH INSURANCE MEDICAL EXAMINATION AND TREATMENT FUND

I. ALLOCATION OF THE HEALTH INSURANCE MEDICAL EXAMINATION AND TREATMENT FUND.

The expenditure on medical examination and treatment by the Vietnam Health Insurance System uses 91.5% of the actual collected health insurance premiums annually, including:

1. Reserve 5% for a medical examination and treatment contingency fund.

2. Allocate 86.5% for the medical examination and treatment fund. The total budget of 86.5% is allocated as follows:

- 5% for primary healthcare;

- 45% for outpatient medical examination and treatment;

- 50% for inpatient treatment.

II. USE OF FUNDS FOR PRIMARY HEALTHCARE

1. Units with corporate healthcare receive 5% of the medical examination and treatment fund calculated based on the unit's health insurance premium contributions from the health insurance agency to purchase medicines and medical supplies for primary healthcare services for the unit's health insurance card holders. The unit with corporate healthcare is responsible for managing and using these funds for their intended purpose, in accordance with current financial regulations, and settling accounts with its superior financial authority, while reporting to the health insurance agency.

2. The list of medicines used in corporate healthcare under the health insurance scheme only includes essential medicines as specified by the Ministry of Health. the regulations of the Ministry of Health.

III. USE OF THE OUTPATIENT MEDICAL EXAMINATION AND TREATMENT FUND

1. The outpatient medical examination and treatment fund of primary healthcare facilities equals 45% of the medical examination and treatment fund calculated based on the total health insurance premium contributions of those who have registered for health insurance medical examination and treatment at such facilities.

2. The outpatient medical examination and treatment fund of primary healthcare facilities is used to cover outpatient medical examination and treatment costs, including those incurred at higher-level facilities.

The health insurance agency settles outpatient medical examination and treatment costs according to the current hospital fee schedule but the total amount settled cannot exceed the outpatient medical examination and treatment fund of the facility.

For healthcare facilities with insufficient outpatient funds due to having fewer initial registration cards but more chronic and severe patients with high outpatient medical examination and treatment costs, the health insurance agency will consider the local outpatient medical examination and treatment fund's balancing capacity to settle the excess costs.

3. District health centers may allocate part of the outpatient medical examination and treatment fund to purchase essential medicines and commonly used medical supplies for commune health stations to provide primary healthcare services for health insurance card holders at commune health stations; the remaining funds are used for outpatient medical examination and treatment at district health centers or higher-level healthcare facilities. The district health center is responsible for managing and allocating the outpatient medical examination and treatment fund to subordinate healthcare facilities and settling accounts for these funds with the health insurance agency.

4. When patients need to be referred to higher-level facilities for outpatient medical examination and treatment:

- Higher-level healthcare facilities receive reimbursement from the health insurance agency for the outpatient medical examination and treatment costs of referred patients outside their own outpatient medical examination and treatment fund.

- Hospitals and institutes without an outpatient medical examination and treatment fund have their outpatient medical examination and treatment costs reimbursed according to the current hospital fee schedule.

The health insurance agency will include all these costs in the outpatient medical examination and treatment costs of the healthcare facility where the insured patient initially registered.

5. At year-end, the provincial health insurance agency may base the balancing capacity of the outpatient medical examination and treatment funds of healthcare facilities in the locality to adjust the outpatient medical examination and treatment funds for healthcare facilities in the province with insufficient outpatient medical examination and treatment funds.

IV. USE OF THE INPATIENT MEDICAL EXAMINATION AND TREATMENT FUND

1. The inpatient medical examination and treatment fund is used to cover inpatient medical examination and treatment costs for patients with health insurance cards. The health insurance agency reimburses inpatient treatment costs for hospitals based on the current hospital fee schedule, but the total settlement for each department does not exceed the ceiling for inpatient treatment cost reimbursement set for each department of the hospital. Excess inpatient medical examination and treatment costs will be reimbursed by the health insurance agency at the end-of-year settlement if the local medical examination and treatment health insurance fund has the capacity to balance.

2. The payment ceiling for inpatient treatment costs (t) of each department or ward shall be calculated by multiplying the average cost (m) of a previous year's inpatient treatment for insured patients according to the hospital fee schedule applicable to each department or ward, by the total number of insured patients who were discharged from that department or ward during the previous year (n), and then by the adjustment factor (k) for each period.

t = m . n . k

The average cost (m) of a previous year's inpatient treatment for insured patients according to the hospital fee schedule applicable to each department or ward shall be determined as follows:

m = a/b

Where:

a = the total cost of inpatient medical examination and treatment for insured patients according to the hospital fee schedule at the department or ward in the previous year.

b = the total number of insured patients who were discharged from the department or ward after receiving inpatient treatment in the previous year.

3. The factor k is used to adjust the payment ceiling for inpatient medical examination and treatment costs to align with actual medical examination and treatment costs and fluctuations in drug and medical supply prices during each period, and is approved by the Health Insurance Management Council and ratified by the Ministry of Health. The factor k has been applied since January 1, 1999, at a rate of 1.1.

4. In special cases where, due to objective reasons (many seriously ill patients with high treatment costs), the inpatient treatment costs exceed the payment ceiling, the hospital and the health insurance agency will collaborate to discuss and consider the excess costs specifically.

C. PAYMENT OF MEDICAL EXAMINATION AND TREATMENT COSTS UNDER HEALTH INSURANCE

I. PAYMENT OF MEDICAL EXAMINATION AND TREATMENT COSTS BETWEEN THE HEALTH INSURANCE AGENCY AND MEDICAL FACILITIES

1. The health insurance agency shall pay medical examination and treatment costs to medical facilities based on the health insurance medical examination and treatment contracts for cases of inpatient and outpatient medical examination and treatment within the designated level of technical expertise, as stipulated in item a, point 3, section I, part A of this Circular.

2. The medical examination and treatment costs for insured patients shall be determined according to the current hospital fee schedule approved by the competent authority; the price of drugs, blood, and intravenous fluids shall be based on the purchase price of the medical facility as prescribed by the Ministry of Health.

3. The health insurance agency is responsible for prepaying medical facilities an amount of funds not less than 70% of the settled medical examination and treatment costs of the previous period. After settlement, the health insurance agency will transfer the remaining amount and implement the advance payment for the next quarter.

4. The medical examination and treatment costs for insured patients when seeking medical care out-of-province shall be appraised and paid by the health insurance agency in the place where the patient receives medical care. This cost will be reimbursed through a multi-line payment method. The General Director of Vietnam Health Insurance will provide detailed guidance on procedures for implementing multi-line payments.

5. To facilitate primary healthcare services at grassroots healthcare facilities and reduce difficulties for insured patients residing in mountainous areas, the co-payment method stipulated in item a, point 3, section I, part A of this Circular shall only apply to medical facilities from district general clinics upwards and shall not apply to insured patients residing in mountainous areas as defined by the Committee for Ethnic Minorities and Mountainous Areas.

6. The medical examination and treatment costs for insured patients may be paid to medical facilities through other methods after mutual agreement between the medical facility and the health insurance agency and approval by the Ministry of Health, ensuring the rights of insured patients and balancing the income and expenditure of the health insurance fund.

II. PAYMENT OF MEDICAL EXAMINATION AND TREATMENT COSTS BETWEEN THE HEALTH INSURANCE AGENCY AND INSURED PATIENTS

1. When insured patients seek medical care within the designated level of technical expertise as stipulated in point 2, section I, part A of this Circular, and if their self-paid expenses in a year exceed six months' minimum wage, the health insurance agency shall reimburse the patient for the additional shared payment they have already paid to the medical facility in that year.

2. For cases of medical care based on individual requests as stipulated in item b, point 3, section I, part A of this Circular, the health insurance agency shall determine the appropriate level of technical expertise based on the diagnosis and treatment techniques provided to the patient, as prescribed by the Ministry of Health, and shall reimburse the insured patient for 80% of the actual medical examination and treatment costs according to the current hospital fee schedule at that level of technical expertise, but not exceeding 80% of the average medical examination and treatment costs at that level of technical expertise. The remaining 20% shall be considered the patient's self-payment portion, which will be reimbursed when the annual self-payment exceeds six months' minimum wage.

- The health insurance agency shall reimburse insured patients for 80% of the actual medical examination and treatment costs incurred for individual requests according to the current hospital fee schedule, but not exceeding 80% of the average medical examination and treatment costs at the appropriate level of technical expertise, with the remaining 20% being the patient's self-payment portion, which will be reimbursed when the annual self-payment exceeds six months' minimum wage.

- Insured patients who are entitled to benefits under the policy for persons with meritorious service to the revolution shall be fully reimbursed for the actual medical examination and treatment costs incurred for individual requests according to the current hospital fee schedule, but not exceeding the average medical examination and treatment costs at the appropriate level of technical expertise, as prescribed by the Ministry of Health.

- Annually, based on statistical reports and settlements approved by the competent authority, Vietnam Health Insurance shall prepare a report on the average medical examination and treatment costs for each level of technical expertise, which will be reviewed by the Health Insurance Management Council and submitted to the Ministry of Health for approval to apply to the reimbursement of medical examination and treatment costs for insured patients seeking medical care based on individual requests in the following year.

The average medical examination and treatment costs for each level of technical expertise, applicable to the reimbursement of medical examination and treatment costs for insured patients seeking medical care based on individual requests in 1999, are specified in the appendix attached to this Circular.

D. IMPLEMENTATION PROVISIONS

1 This Circular takes effect from January 1, 1999. Previous regulations inconsistent with this Circular are hereby abolished.

2. The Ministry of Health assigns the Vietnam Health Insurance, the Health Departments of provinces and centrally governed cities, and the health departments under ministries and sectors to direct their subordinate units to implement the provisions of this Circular.

During the implementation process, if there are difficulties or obstacles, the units and localities need to promptly reflect them to the Ministry of Health (Treatment Department) for research and consideration to supplement and amend appropriately.

ANNEX

AVERAGE MEDICAL EXPENSES FOR DIAGNOSIS AND TREATMENT IN 1999
AT SPECIALIZED TECHNICAL TRENDS, APPLICABLE FOR PAYMENT OF HEALTH INSURANCE CARD HOLDERS SEEKING MEDICAL CARE AS REQUIRED
(Annexed by Circular No. 17/1998/TT-BYT dated December 19, 1998)

a) Average cost for one outpatient visit and medication

b) Average cost for one inpatient treatment episode