Joint Circular No. 21/2005/TTLT/BYT-BTC guiding the implementation of mandatory health insurance

JOINT CIRCULAR

Guidelines for Compulsory Health Insurance Implementation

Based on the Health Insurance Regulations issued together with Decree No. 63/2005/NĐ-CP dated May 16, 2005 of the Government;

The Ministry of Health and the Ministry of Finance hereby provide guidelines for the implementation of compulsory health insurance (BHYT) as follows:

PART I

OBJECTS, CONTRIBUTION LEVELS, RESPONSIBILITIES AND METHODS OF PAYING HEALTH INSURANCE PREMIUMS

I. OBJECTS, CONTRIBUTION LEVELS, RESPONSIBILITIES AND METHODS OF PAYING HEALTH INSURANCE PREMIUMS

The objects subject to compulsory health insurance, contribution levels, responsibilities, and methods of paying health insurance premiums shall be applied as follows:

1. Vietnamese workers (hereinafter referred to as workers) who work under labor contracts with a term of three months or more and indefinite-term labor contracts in the following enterprises and organizations:

a) Enterprises established and operating under the Law on State-Owned Enterprises, including production and business enterprises, public service enterprises, and enterprises belonging to the armed forces;

b) Enterprises established and operating under the Enterprise Law, including limited liability companies, joint-stock companies, partnerships, and private enterprises;

c) Enterprises established and operating under the Law on Foreign Investment in Vietnam, including joint ventures and wholly foreign-owned enterprises;

d) Enterprises in agriculture, forestry, fisheries, and salt industries;

đ) Cooperatives established and operating under the Law on Cooperatives;

e) Enterprises of political organizations and political-social organizations;

g) State agencies, public institutions, armed forces, political organizations, political-social organizations, occupational social organizations, other social organizations (including those permitted to engage in production, business, and services under Party, mass organizations, and people's associations self-financed);

h) Commune, ward, and town health stations;

i) Public kindergartens;

k) Offices, organizations of foreign countries or international organizations in Vietnam, except where international treaties, multilateral or bilateral agreements to which the Socialist Republic of Vietnam is a party provide otherwise;

l) Semi-public, privately-run, and private establishments in culture, healthcare, education, training, science, sports, and other public services;

m) Other organizations employing workers that have been legally established and operate;

Workers specified in Clause 1 above, if working under labor contracts with a term of less than three months, when their labor contracts expire and they continue working or enter into new labor contracts with employers, must participate in compulsory health insurance.

For the objects specified in Clause 1 above, the monthly health insurance contribution rate is 3% of the salary according to rank and position, monthly remuneration recorded in the labor contract, and allowances for leadership positions, seniority, seniority beyond the standard, regional allowances, and retention coefficient (if applicable). Among these, the employer contributes 2%, while the worker contributes 1%. Employers are responsible for deducting the health insurance contributions within their responsibility and collecting the health insurance contributions from workers at the prescribed ratio to pay to the Social Insurance Agency (BHXH) on a monthly basis.

The State encourages employers in enterprises to fully cover the health insurance premiums for workers. In this case, the enterprise will account for 2% of the premium as part of production costs and 1% from the enterprise fund.

Civil servants, officials, and employees under the Civil Servants and Officials Ordinance: The monthly health insurance contribution rate is 3% of the salary according to rank and position, and allowances for leadership positions, seniority, seniority beyond the standard, regional allowances, and retention coefficient (if applicable). Among these, the management agency of civil servants, officials, and employees is responsible for contributing 2%, while civil servants, officials, and employees contribute 1%.

The management agency of civil servants, officials, and employees is responsible for deducting the health insurance contributions and collecting the health insurance contributions from civil servants, officials, and employees at the prescribed ratio to pay to the Social Insurance Agency (BHXH) on a monthly basis.

The salary, remuneration, and allowances for health insurance contributions for the objects specified in Clauses 1 and 2 above are consistent with the salary, remuneration, and allowances for social insurance contributions.

3. Persons currently receiving monthly pension or disability benefits: The monthly health insurance contribution rate is 3% of the monthly pension or disability benefit. The Social Insurance Agency will prepare a list and pay the entire 3%.

4. Village, ward, and town cadres who have retired and are currently receiving monthly social insurance benefits as stipulated in Decree No. 09/1998/NĐ-CP dated January 23, 1998 of the Government, persons currently receiving monthly social insurance benefits as stipulated in Decision No. 91/2000/QĐ-TTg dated August 4, 2000 of the Prime Minister, persons currently receiving monthly compensation for work-related accidents or occupational diseases, not belonging to other compulsory health insurance objects; rubber plantation workers who have retired and are currently receiving monthly social insurance benefits: The monthly health insurance contribution rate is 3% of the national minimum wage. The Social Insurance Agency will prepare a list and pay the entire 3%.

The state budget ensures funding for health insurance contributions for individuals who retired and received pensions or social insurance benefits before October 1, 1995. The Social Insurance Fund ensures funding for health insurance contributions for individuals who retired and received pensions or social insurance benefits from October 1, 1995 onwards.

5. Current National Assembly deputies and People's Council deputies at all levels who are not part of the state payroll or payroll of political-social organizations and do not receive monthly social insurance benefits, and are not part of other compulsory health insurance objects: The monthly health insurance contribution rate is 3% of the national minimum wage. The Provincial People's Council will prepare a list and pay the health insurance premium for National Assembly deputies from the local delegation. Each level People's Council is responsible for preparing a list and paying the health insurance premium for deputies of that level. The state budget ensures funding for health insurance contributions for this object according to the current state budget classification.

5. Deputies to the National Assembly and current People's Council deputies at all levels who are not part of the state civil service, the civil service of political-social organizations, or those not receiving monthly social insurance benefits shall contribute to mandatory health insurance at a rate of 3% of the national minimum wage. The People's Councils of provinces and centrally governed cities shall prepare lists and pay the health insurance premiums for National Assembly deputies belonging to their respective provincial-level delegations. Each level of People's Council shall be responsible for preparing lists and paying the health insurance premiums for People's Council deputies at that level. The state budget shall ensure funding for the payment of health insurance premiums for these individuals according to the current state budget classification.

6. Persons who have rendered meritorious service to the revolution and are currently receiving monthly social preferential allowances as prescribed, and who do not fall under the mandatory health insurance participation categories specified in Clauses 1, 2, 3, 4, and 5 above, b) Explanation and calculation of cost components and profit of Electricity Corporation i, including:

a) Persons who were engaged in revolutionary activities before August 1945;

b) Wives (or husbands), biological parents, and children of martyrs, persons who raised martyrs;

c) Heroes of the Armed Forces, Labor Heroes, Mothers of Vietnam's Heroic Generation;

d) War invalids, persons enjoying policies equivalent to those for war invalids with a labor capacity reduction of 21% or more due to disabilities, including Class B war invalids recognized prior to December 31, 1993;

đ) Persons who were engaged in revolutionary or anti-enemy resistance activities and were captured and imprisoned by the enemy, holding certificates as prescribed;

e) War invalids with a labor capacity reduction of 61% or more due to illness, including Class 3 war invalids with a labor capacity reduction of 41% to 60%, recognized prior to December 31, 1994;

g) Persons who have contributed to the revolution;

h) Persons receiving allowances for serving and the first and second children under 18 years old of war invalids with a labor capacity reduction of 81% or more;

i) Other subjects as prescribed by law.

The monthly health insurance contribution rate for the aforementioned subjects shall be 3% of the national minimum wage. The Department of Labor, Invalids, and Social Affairs shall prepare a list and pay the full 3% from the state budget.

7. Persons who participated in the resistance and their children born to them who were affected by chemical toxins used by the United States during the war in Vietnam and are currently receiving monthly allowances: The monthly health insurance contribution rate shall be 3% of the national minimum wage. The Department of Labor, Invalids, and Social Affairs shall prepare a list and pay the full 3% from the state budget.

8. Village cadres who retired due to old age and are currently receiving monthly allowances as prescribed in Decision No. 130/CP dated June 20, 1975 of the Council of Ministers (now the Government) and Decision No. 111/HĐBT dated October 13, 1981 of the Council of Ministers (now the Government): The monthly health insurance contribution rate shall be 3% of the national minimum wage from the village budget. The People's Committee of the village where the subject receives the allowance shall prepare a list, register with the Health Insurance Agency, and pay the full 3%.

9. Relatives of officers of the People's Army of Vietnam on active duty; relatives of officers working in the Public Security Force, who do not fall under other mandatory health insurance categories, include:

a) Biological fathers and mothers of officers; biological fathers and mothers of the spouses of officers;

b) Foster fathers, foster mothers, or legal guardians of officers, or of the spouses of officers;

c) Spouses of officers;

d) Biological or legally adopted children under 18 years old of officers; biological or legally adopted children aged 18 or older but disabled and unable to work according to the law.

The monthly health insurance contribution rate for the relatives of officers shall be 3% of the national minimum wage. The Ministry of National Defense and the Ministry of Public Security (after coordinating with the Ministry of Health and the Ministry of Finance) shall provide guidance on the responsibility and method of paying health insurance contributions for this group.

10. Social welfare beneficiaries: The monthly health insurance contribution rate shall be 3% of the national minimum wage.

- The People's Committee of the commune shall prepare a list and pay the full 3% for social welfare beneficiaries receiving monthly allowances living in the community from the commune budget.

- Care centers and social welfare centers shall prepare a list and pay the full 3% for beneficiaries living in the center from the state budget allocated to the center.

11. Elderly people aged 90 or older and elderly people with disabilities without support who are provided monthly allowances in the community or are cared for in centralized care facilities (not included in other mandatory health insurance categories): The temporary monthly health insurance contribution rate is 50,000 VND/person/year.

- The People's Committee of the commune shall prepare a list and pay the health insurance fee according to regulations for residents in the commune from the commune budget.

- Care facilities shall prepare a list and pay health insurance for individuals being cared for at the facility from the state budget allocated to the facility.

12. Subjects entitled to medical examination and treatment benefits for the poor. The temporary monthly health insurance contribution rate is 50,000 VND/person/year. The Department of Labor, Invalids, and Social Affairs shall prepare a list and purchase health insurance for these subjects from the state budget.

13. Former soldiers from the period of fighting against France and America, in addition to those already participating in mandatory health insurance as prescribed above, include military personnel and defense workers who fought and served in units of the Vietnam People's Army before April 30, 1975: The monthly health insurance contribution rate shall be 3% of the national minimum wage, guaranteed by the state budget. The Association of Former Soldiers where the subject resides shall prepare a list and send it to the People's Committee of the commune, township, or town for submission to the Association of Former Soldiers at the district level. The Association of Former Soldiers at the district level shall compile and submit to the Association of Former Soldiers at the provincial level for approval and report to the People's Committee at the provincial level to allocate the budget according to the current budget classification.

14. Foreign students studying in Vietnam and receiving scholarships from the Vietnamese government: The health insurance contribution rate shall be 3% of the monthly scholarship, prepared by the scholarship-granting agency and paid in full.

II. ISSUANCE, MANAGEMENT, AND USE OF HEALTH INSURANCE CARDS

1. Health insurance cards are issued by the Health Insurance Agency to persons participating in health insurance, identifying the named person entitled to health insurance benefits within the period indicated on the card. Health insurance cards are issued by the Vietnam Health Insurance and uniformly managed nationwide.

2. Each person participating in mandatory health insurance is only issued one health insurance card. In cases where a person falls under two or more mandatory health insurance categories, they must choose one category according to the order specified in Section I, Part I of this Circular, with health insurance benefits based on the highest benefit group. Organizations, units, and entities must prepare lists of subjects and the Health Insurance Agency has the responsibility to review and ensure there are no duplicate subjects.

3. Health insurance cards become valid immediately and continuously from the date of payment of health insurance premiums in accordance with regulations. To ensure continuous validity of the health insurance card, organizations, units, entities, and employers have the responsibility to renew the health insurance card registration, notify changes in the status of the subjects they manage to the Health Insurance Agency. The issuance, replacement, and exchange of health insurance cards by the Health Insurance Agency must ensure continuity and timeliness, without affecting the rights of health insurance participants.

4. The health insurance card shall not be valid for use in the following cases:

a) The card is not issued by the social insurance agency;

b) It has exceeded its validity period as indicated on the card;

c) The card has been altered, erased, torn, or damaged;

d) The named person on the card has died or is currently incarcerated;

đ) Using another person's health insurance card to seek medical examination and treatment.

5. Organizations, units, entities, and employers have the responsibility to accept health insurance cards issued by the social insurance agency and promptly hand them over to the individuals under their management. In case of loss of the health insurance card, they must immediately report to the social insurance agency that issued the card to apply for a replacement if there is a legitimate reason.

6. The Vietnam Social Security will provide specific guidelines for issuing health insurance cards to ensure promptness, convenience, and accuracy.

PART II

SCOPE OF RIGHTS AND BENEFITS OF HEALTH INSURANCE CARD HOLDERS

 I. RIGHTS AND BENEFITS OF HEALTH INSURANCE CARD HOLDERS

1. Health insurance card holders with valid compulsory health insurance cards when seeking outpatient and inpatient medical examination and treatment at public and non-public medical facilities that have contracts with the social insurance agency for medical examination and treatment services (hereinafter referred to as health insurance medical facilities) shall enjoy the following benefits:

a) Medical examination, diagnosis, treatment, and rehabilitation functions (as specified in the list prescribed by the Ministry of Health) during the treatment period at the medical facility;

b) Laboratory tests, imaging diagnostics, and functional examinations;

c) Medicines and intravenous fluids within the list prescribed by the Ministry of Health;

d) Blood and blood products;

đ) Surgical procedures and medical interventions;

e) Prenatal care and childbirth;

g) Use of medical supplies, equipment, and hospital beds;

h) Transportation costs when transferring to a higher-level medical facility according to the regulations of the Ministry of Health for people living in poverty, those eligible for social welfare policies (as stipulated in Clause 6, 7, 10, 11, and 12, Section I, Part I of this Circular), and those residing or working in areas I, II, and III as defined by the Ethnic Minorities Commission based on the criteria set forth in Circular No. 41/UB-TT dated January 8, 1996 of the Ethnic Minorities Commission and Mountainous Areas (now the Ethnic Minorities Commission);

2. Compulsory health insurance card holders when receiving medical examination and treatment at the registered primary healthcare facility and other health insurance medical facilities introduced for transfer according to the specialized technical level as prescribed by the Ministry of Health, or in emergency situations at health insurance medical facilities, shall have their medical examination and treatment costs covered by the social insurance agency at the current state hospital fee rates.

3. When using high-cost medical services:

3.1. The Health Insurance Fund will cover 100% of the cost of high-cost medical services with fees below seven million dong.

3.2. For high-cost medical services with fees from seven million dong or more, the payment will be made as follows:

a) For subjects who were engaged in revolutionary activities before August 1945, Mothers of Vietnam Heroes, war invalids, disabled veterans, and those entitled to benefits equivalent to war invalids with a disability rate of 81% or higher, and elderly persons aged 90 years or older: The Health Insurance Fund will cover 100% of the service cost.

b) For those who have contributed to the revolution and are receiving monthly allowances (excluding the subjects mentioned in point (a) above); those who participated in the resistance war and their children affected by toxic chemicals used by the US in the Vietnam War and are receiving monthly allowances; elderly persons with disabilities without support; those receiving monthly pensions, monthly social insurance allowances, and monthly social assistance; and those receiving medical examination and treatment benefits for the poor: The Health Insurance Fund will cover 100% of the service cost but not exceeding twenty million dong per use.

c) For all other subjects: The Health Insurance Fund will cover 60% of the cost but not exceeding twenty million dong per use, with the remaining amount to be paid by the insured patient to the medical facility. If 60% of the cost is less than seven million dong, the Health Insurance Fund will pay seven million dong.

Example: Patient Nguyen Van A used a high-cost medical service with a fee of ten million dong. According to point (c) above, patient A will be reimbursed by the Health Insurance Fund at 60% of ten million dong, which equals six million dong. Since this amount is lower than seven million dong, patient A will be reimbursed seven million dong. The remaining three million dong will be paid by patient A to the hospital.

3.3. The Ministry of Health will issue a list of high-cost medical services after coordinating with the Ministry of Finance to provide the basis for the social insurance agency to settle accounts with medical facilities.

4. Transportation costs for patients as stipulated in Point (h), Clause 1, Section I, Part II of this Circular shall be settled as follows:

a) In cases where patients are transported by the medical facility's means of transportation, the social insurance agency will reimburse the transportation costs to the medical facility at a rate not exceeding 0.2 liters of gasoline per kilometer traveled (for both the outbound and return trips) based on the current price at the time of use. If multiple patients are transported in the same vehicle, the reimbursement will still be calculated as if only one patient was transported.

b) In cases where patients do not use the medical facility's means of transportation, the medical facility introducing the patient for transfer will reimburse the patient at a rate of thirty thousand dong per hundred kilometers (for a single trip).

5. When seeking medical examination and treatment according to personal requirements:

a) Patients with health insurance cards who receive medical examination and treatment within the appropriate specialized technical level but choose their own doctors, rooms, and additional medical services will be reimbursed by the Health Insurance Fund at the current state hospital fee rates applicable to the medical facility. The patient will bear the difference between the cost of the requested services and the state-prescribed hospital fee. If the patient requests services beyond the medical prescription, the patient will bear the full cost of those services.

b) Patients with health insurance cards who seek medical examination and treatment outside the appropriate specialized technical level as prescribed by the Ministry of Health or at medical facilities without contracts with the social insurance agency will be reimbursed by the social insurance agency based on actual costs but not exceeding the average cost for each type of medical examination and treatment at the appropriate specialized technical level (as stipulated in the Appendix attached to this Circular). In the case of medical treatment abroad, the social insurance agency shall reimburse according to the average cost of central hospitals in Hanoi and Ho Chi Minh City.

6. A person with mandatory health insurance card when receiving medical treatment at the initial registered medical facility which is a non-public medical institution that has signed a health insurance medical service contract, shall be reimbursed by the social insurance agency according to the hospital fee prices for medical services provided by state-owned medical facilities at the appropriate level of expertise. The patient shall pay the difference (if any) between the hospital fee price of the non-public medical institution and the agreed payment amount by the social insurance agency.

II. CASES NOT ENTITLED TO HEALTH INSURANCE BENEFITS

The social insurance agency will not cover the costs of medical treatment in the following cases:

1.  Treatment of leprosy;

2. Special drugs for treating tuberculosis, malaria, schizophrenia, epilepsy, and other diseases if such costs have already been covered by the state budget through national health programs, projects, or other sources of funding;

3. Diagnosis and treatment of HIV/AIDS (except for HIV tests required by professional instructions and those specified in Decision No. 265/2003/QD-TTg dated December 16, 2003 of the Prime Minister on the regime for individuals exposed to HIV, infected with HIV/AIDS due to occupational accidents or risks, gonorrhea, syphilis);

4. Vaccination, convalescence, early pregnancy testing, health check-ups including regular health check-ups, pre-employment health examinations, pre-military service health examinations, family planning services, and infertility treatments;

5. Cosmetic surgery and aesthetic reconstruction, artificial limbs, artificial eyes, dentures, glasses, hearing aids;

6. Treatment of occupational diseases; work-related accidents (accidents during working hours at the workplace, including overtime work requested by the employer; accidents outside the workplace while performing tasks requested by the employer; accidents on the route from home to the workplace); war injuries; natural disaster-related injuries;

7. Treatment of suicide attempts, intentional bodily harm, drug addiction, or conditions resulting from illegal activities;

8. Costs associated with medical examination, forensic medical examination, forensic psychiatric examination;

9. Medical care, rehabilitation, and childbirth at home;

10. Use of medicines not listed in the prescribed directory, medicines requested by the patient; use of unapproved medical methods by the Ministry of Health; participation in research and clinical trials.

PART III

MANAGEMENT AND USE OF THE HEALTH INSURANCE FUND

I. HEALTH INSURANCE FUND

1. The health insurance fund is formed from the following sources:

a) Health insurance premiums paid by the state budget, employers, and insured persons as stipulated;

b) State budget funds allocated to purchase health insurance cards for eligible groups as prescribed;

c) Revenue from donations and grants from organizations and individuals both domestically and internationally;

d) Other government support and lawful revenues (if any).

đ) Income generated from implementing legal measures to preserve and grow the health insurance fund;

2. The health insurance fund is a component of the social insurance fund, managed centrally, uniformly, democratically, and transparently in accordance with the current financial management regulations for the Vietnam Social Security.

The health insurance fund is used to reimburse medical treatment and rehabilitation expenses for insured persons within the scope of benefits as prescribed.

Any temporarily unused funds (if any) of the mandatory health insurance fund shall be mobilized to implement measures to preserve and grow the fund as prescribed.

II. MANAGEMENT AND USE OF THE FUND

1. Management of the health insurance fund

a) The health insurance premium payments (points (a) and (b) Clause 1 Section I Part III) are allocated and used as follows:

·        95% to establish the medical treatment fund;

·        5% to establish the medical treatment reserve fund.

b) The revenue specified in points (c) and (d) Clause 1 Section I Part III (if any) will be recorded in the medical treatment fund.

c) The revenue specified in point (đ) Clause 1 Section I Part III will be recorded in the medical treatment reserve fund after deducting the management costs as stipulated in the current financial management regulations for the Vietnam Social Security.

d) Any remaining balance of the medical treatment fund at the end of each year shall be transferred to the medical treatment reserve fund.

đ) In the event that the medical treatment fund's expenditure exceeds its capacity to pay in a given year, the medical treatment reserve fund shall be used to supplement it. If the reserve fund is exhausted, temporary advances may be made from other surplus funds of the social insurance fund to ensure timely and full payment of benefits as prescribed under the current financial management regulations for the Vietnam Social Security. After the annual financial settlement report is approved, the Vietnam Social Security Management Council will coordinate with relevant ministries to report and submit a repayment plan for the social insurance funds to the Prime Minister.

2. Use of the medical treatment fund

The health insurance medical treatment fund is used to reimburse outpatient and inpatient medical treatment costs at the initial registered medical facility and the medical treatment costs of insured persons who need to transfer to another facility, special medical treatment, and transportation costs for patients.

3. Balancing and regulating the medical treatment fund

a) Every six months and annually, the provincial social insurance agency shall compile the usage situation of the medical treatment fund at medical facilities within their jurisdiction. In the event of a deficit in the medical treatment fund, it shall be reported to the Vietnam Social Security for resolution.

b) Within the scope of the health insurance fund's usage, the Vietnam Social Security shall regulate the medical treatment fund to ensure sufficient funding for provincial social insurance agencies to reimburse medical treatment costs to medical facilities.

PART IV

ORGANIZATION OF MEDICAL TREATMENT AND

REIMBURSEMENT OF MEDICAL TREATMENT COSTS UNDER HEALTH INSURANCE

I. ORGANIZATION OF MEDICAL TREATMENT UNDER HEALTH INSURANCE

1. Health insurance medical treatment facilities

a) Public medical facilities meeting the prescribed standards in terms of professional technical qualifications shall provide medical treatment to patients with health insurance cards, including: Commune Health Stations, Ward Health Stations, or Health Rooms of various agencies and enterprises; Regional Polyclinics; Maternity Houses; Hospitals and Institutes with beds.

b) Non-state healthcare facilities, including multi-specialty clinics, specialty clinics, midwifery houses, and hospitals, may enter into contracts for health insurance medical services if they meet the legal requirements and have their fee levels and payment mechanisms approved, similar to state-owned healthcare facilities.

2. Selection and registration of initial healthcare facilities and referral for medical examination and treatment

a) Individuals with health insurance cards may choose one of the convenient initial healthcare facilities near their place of residence or workplace, as guided by the Social Insurance Authority, to be managed and treated. The registered initial healthcare facility will be recorded on the health insurance card.

b) Individuals with health insurance cards have the right to request the Social Insurance Authority to change their registered initial healthcare facility at the end of each quarter.

c) For professions with special characteristics where individuals with health insurance cards frequently move or work in different regions, the Social Insurance Authority is responsible for coordinating with labor management agencies and healthcare facilities in the area to determine healthcare facilities and payment methods that are convenient and ensure the rights of individuals with health insurance cards.

d) For maternity services: Individuals with health insurance cards must register for prenatal care and childbirth at health stations, multi-specialty clinics, midwifery houses, district, county, town, city-level hospitals, provincial, centrally-administered municipal hospitals.

đ) When the medical condition of an individual with a health insurance card exceeds the professional technical capacity of the healthcare facility, the patient will be referred for treatment according to the regulations of the Ministry of Health.

e) In emergency cases, individuals with health insurance cards can receive treatment at any healthcare facility within Vietnam (including both public and non-public healthcare facilities) and enjoy full health insurance benefits.

3. Necessary procedures when seeking health insurance medical examination and treatment

a) When receiving treatment at the registered initial healthcare facility, individuals with health insurance cards must present their valid health insurance card and an identity document with a photograph.

b) For follow-up examinations as scheduled by the doctor, individuals with health insurance cards must present the aforementioned documents and discharge papers with a follow-up appointment or a follow-up appointment letter from the healthcare facility (or recorded in the medical record book) according to hospital regulations set by the Ministry of Health.

c) For hospital transfers: individuals with health insurance cards must present the aforementioned documents and transfer records as required (including the Transfer Introduction Letter and Summary of Medical Records from the treating healthcare facility).

d) Patients must immediately present their health insurance card and necessary documents as stipulated above when receiving treatment. If presenting the card late, they will only be entitled to health insurance benefits from the day the card was presented. Patients must pay the healthcare facility for medical expenses incurred before presenting the card, which will then be reimbursed by the Social Insurance Authority as with other requested treatments. For emergency cases or unconscious patients without accompanying relatives, patients must present their health insurance card before discharge to be eligible for health insurance benefits.

4. Organization of health insurance medical examination and treatment for patients

Healthcare facilities providing health insurance services are responsible for organizing medical treatment for individuals with health insurance cards according to the signed contracts with the Social Insurance Authority to ensure the best interests of health insurance participants, specifically:

a) Organizing reception and guiding individuals with health insurance cards upon arrival for treatment.

b) Checking and managing health insurance cards and transfer letters (if the patient is a transferred patient) immediately upon the patient's arrival for treatment. During the time the patient with a health insurance card is hospitalized, the healthcare facility will manage the patient's card and return it upon discharge or transfer.

c) In cases exceeding professional capabilities, the healthcare facility is responsible for transferring the patient according to the regulations on professional technical levels and the regulations and procedures for transferring patients set by the Ministry of Health.

d) The healthcare facility ensures the provision of quality medical treatment for patients, ordering necessary laboratory tests, imaging diagnostics, functional examinations, and specialized techniques reasonably and safely in accordance with regulations.

đ) Prescribing and dispensing medication to patients, both inpatient and outpatient, according to the drug list prescribed by the Ministry of Health, without issuing prescriptions for patients to purchase drugs themselves. If prescribing drugs based on patient requests, it must be clearly noted "Prescribed at patient's request" as the basis for health insurance reimbursement.

e) Based on the scope of professional technical capabilities, healthcare facilities are responsible for ensuring sufficient supply of medications, blood, intravenous fluids, chemicals, medical supplies, etc., to support medical activities and facilitate patients, as well as facilitating payments between healthcare facilities and the Social Insurance Authority.

g) When accepting patients transferred from elsewhere, if deemed unnecessary for inpatient treatment, the receiving healthcare facility has the responsibility to dispense outpatient treatment medications or provide treatment instructions and refer the patient to an appropriate level of specialized treatment, without issuing prescriptions for patients to purchase drugs themselves.

h) Cooperating with social insurance officers stationed at healthcare facilities to explain health insurance policies and resolve complaints related to the rights of individuals with health insurance cards.

i) Strictly implementing the recording of costs for healthcare services used by insured patients, accurately documenting all relevant information during the treatment process to serve as the basis for payment with the Social Insurance Authority.

k) Provincial and centrally-administered municipal health departments and health management agencies under various ministries and sectors are responsible for directing subordinate healthcare facilities to properly implement health insurance medical treatment activities in accordance with regulations, managing professional activities to ensure effective, reasonable, and safe implementation of medical orders, and resolving violations by subordinate healthcare facilities in providing treatment to individuals with health insurance cards within their authority.

II. FORMS OF PAYMENT FOR HEALTH INSURANCE MEDICAL EXAMINATION AND TREATMENT COSTS

1. Payment between the Social Insurance Authority and healthcare facilities

The Social Insurance Authority pays medical service costs to healthcare facilities based on health insurance medical service contracts for cases of correct professional technical level treatment or emergencies, through either service fee payment or fixed rate payment methods. Healthcare facilities select the appropriate payment method to sign a contract with the Social Insurance Authority.

1.1. Payment according to service fees

a) Principles and Content of Payment

- Service fee payment is a form of payment based on the costs of medical services used by insured patients under the BHYT scheme. The costs for medicines, medical consumables, and infusions are reimbursed according to the purchase price of the healthcare facility; the costs for blood and blood products are reimbursed according to the prescribed prices. Other medical service costs are based on the Hospital Fee Schedule approved by the competent authority in accordance with regulations on hospital fees.

- The level of outpatient care fees at commune health centers is temporarily set by the Chairman of the People's Committee of the province or centrally-administered city based on the fee schedule applicable to district-level hospitals as stipulated by the Ministry of Health and the Ministry of Finance.

- For non-public healthcare facilities that have signed contracts for BHYT healthcare services, the corresponding public facility’s fee schedule for the same specialty level shall be applied.

b) Payment Methods

- For healthcare facilities providing both outpatient and inpatient services (where insured individuals have registered for initial healthcare), the facility may use 90% of the healthcare fund (based on the total number of registered cards at the average BHYT fee level of the province or centrally-administered city) to cover outpatient and inpatient treatment costs and transportation expenses for insured patients registered at that facility, as well as treatment costs at other facilities when patients are referred, treated in emergencies, or receive special treatments.

- For healthcare facilities providing only outpatient services (where insured individuals have registered for initial healthcare), the facility may use 45% of the healthcare fund (based on the total number of registered cards at the average BHYT fee level of the province or centrally-administered city) to cover outpatient treatment costs at the registered facility; outpatient treatment costs at other facilities when patients are referred, treated in emergencies, or receive special treatments, and transportation costs if there is a transfer to another facility. The remaining portion of the healthcare fund will be used by the Social Security agency to reimburse inpatient treatment costs at other facilities where patients receive inpatient care.

- For commune health centers: The Social Security agency signs a contract with the county general hospital (or another healthcare facility assigned by the provincial Department of Health to provide healthcare services to residents in districts, counties, towns, and cities within the province in cases where there is no county hospital) to organize healthcare services for insured individuals who have registered for initial healthcare at the commune health center.

Within the allocated healthcare fund for BHYT, the county hospital (or the assigned healthcare facility) is responsible for purchasing medications and medical supplies for the commune health center and paying for technical services provided by the commune health center in accordance with regulations.

- The Social Security agency implements reimbursement of healthcare costs for insured individuals at other BHYT healthcare facilities and deducts the corresponding amount from the healthcare fund used by the initial registration healthcare facility.

- In cases where the healthcare costs exceed the allocated healthcare fund, the healthcare facility will be compensated by the Social Security agency from 10% of the remaining healthcare fund of facilities providing both outpatient and inpatient services, or from 5% of facilities providing only outpatient services.

- If compensation still leaves a shortfall due to fewer initial registration cards, more patients with serious or chronic diseases requiring high treatment costs, or due to the specific nature of the patient population served by the healthcare facility, the Social Security agency is responsible for balancing the BHYT fund to promptly cover the excess costs, ensuring the rights of patients and healthcare facilities.

- The Social Security agency is responsible for pre-funding a minimum amount equal to 80% of the previous quarter's settled healthcare costs for healthcare facilities, and upon settlement, both parties reconcile and adjust, with the Social Security agency making advance payments for the next quarter. By the end of November each year, the Social Security agency is responsible for pre-funding to allow healthcare facilities to proactively purchase medications and medical supplies for the following year.

1. 2. Payment Based on Quota

a) Principles

- Payment based on quota is a method where the Social Security agency reimburses healthcare facilities based on a quota (or quota rate) calculated per insured individual (or per BHYT card) registered at the healthcare facility over a specified period (one year).

- The total annual quota fund shall not exceed 90% of the healthcare fund used for BHYT patients for facilities providing both outpatient and inpatient services, and 45% for facilities providing only outpatient services. The remaining portion of the fund will be used by the Social Security agency for adjustment and modification of the quota rate as necessary.

- Based on the determined total quota funding, the Social Security agency is responsible for pre-funding the healthcare facilities and implementing settlement and reimbursement.

- Healthcare facilities must ensure healthcare services for the number of insured individuals registered during the agreed period without charging any additional costs within the scope of benefits covered by the BHYT regulations.

- Healthcare facilities must cover all healthcare costs under the BHYT scheme for insured individuals registered at their facility, including treatment costs at other levels.

- Healthcare facilities can only use this quota fund for ensuring healthcare costs and improving the quality of BHYT healthcare services, not for other purposes.

- In cases where actual healthcare costs exceed the quota due to external factors such as epidemics, increases in chronic diseases, etc., the Social Security agency will consider and adjust to support the shortfall.

- The quota rate will be adjusted to suit changes in medical costs, BHYT contribution rates, and the specific characteristics of the disease structure of insured individuals registered at each healthcare facility.

b) Method

- Determining the quota: The total payment amount (C) made by the Social Security agency to the healthcare facility is calculated as follows:

C = M x N x k

Where:

·        M is the quota rate per BHYT card

·        N is the total number of BHYT cards registered at the facility for the year

·        k is the adjustment factor due to changes in healthcare costs from the previous year. The temporary factor k is 1.1. In cases of sudden increases in healthcare costs, the Ministry of Health and the Ministry of Finance will adjust the factor accordingly.

- Calculating the quota rate (M): The average quota rate per card is determined as follows:

M = M1 + M2 + M3

Where:

· M1 is the average outpatient healthcare cost per card per year;

· M2 is the average inpatient healthcare cost per card per year;

· M3 is the average transportation cost per card per year.

- The basis for calculating the average cost is based on the costs of the previous year.

2. Direct payment between the Social Insurance agency and the health insurance participants

a) The Social Insurance agency makes direct payments to individuals with health insurance cards in the following cases:

- Out-of-network specialized technical medical care according to the regulations of the Ministry of Health;

- Medical care at healthcare facilities without contracts with the Social Insurance agency;

- Medical care abroad.

b) In the cases specified in point (a) of Clause 2 above, patients pay their own medical expenses to the healthcare facility, while retaining all valid documents (prescriptions, medical records, drug purchase invoices, discharge papers, hospital fee receipts as stipulated by the Ministry of Finance, and other related documents) to request the Social Insurance agency to reimburse part of the medical expenses according to the provisions of point (b) of Clause 5 of Section I, Part II of this Circular.

3. Other payment methods

The Social Insurance agency and healthcare facilities study and propose other payment methods such as: payment based on diagnosis, payment based on average inpatient days... ensuring the rights of health insurance patients, the rights of healthcare facilities, and the safety of the health insurance fund to be submitted to the Vietnam Social Insurance for consideration and reported to the joint decision of the Ministry of Health and the Ministry of Finance.

4. The source of funds for the Social Insurance agency to pay healthcare facilities is the hospital revenue of the unit, managed and used according to current state regulations.

PART V

RIGHTS AND OBLIGATIONS OF THE SOCIAL INSURANCE AGENCY AND HEALTHCARE FACILITIES

I. FOR THE SOCIAL INSURANCE AGENCY

1. Issue health insurance cards to eligible persons within the prescribed time frame.

2. Guide health insurance cardholders to choose convenient initial healthcare registration locations.

3. Sign contracts and cooperate effectively with legitimate healthcare facilities to provide medical care for health insurance cardholders.

4. Provide forms and guidance materials for healthcare facilities to record and statistically track the medical costs of health insurance cardholders. Provide relevant data such as: number of health insurance cards registered for initial healthcare, average health insurance fees of the province/city to determine the healthcare fund of the healthcare facility.

5. Cooperate with healthcare facilities to check necessary documents that health insurance cardholders must present when seeking medical care and resolve complaints related to the rights of health insurance cardholders when seeking medical care.

6. Be provided by healthcare facilities with patient files, medical records, and other relevant documents related to medical care and expense reimbursement to ensure the rights of health insurance cardholders and serve as a basis for settlement with healthcare facilities.

7. Refuse to pay medical expenses not in accordance with the Health Insurance Regulations and the provisions of this Circular or not consistent with the terms of the healthcare contract between the Social Insurance agency and the healthcare facility; detect cases of misuse of health insurance cards and misuse of the health insurance fund to address them within its authority.

8. Timely and properly implement advance payments, settlement, and reimbursement of medical expenses for health insurance cardholders with healthcare facilities according to regulations and deadlines. Guide and make direct payments to health insurance cardholders at the Social Insurance agency in a timely manner and in accordance with regulations.

9. The provincial Social Insurance agency regularly every quarter (or after each settlement period) takes the lead and cooperates with the Department of Health to compile, evaluate the situation of healthcare fund usage locally and the protection of health insurance cardholders' rights when seeking medical care at healthcare facilities within the province to report to the Vietnam Social Insurance and the Ministry of Health for consideration and resolution.

10. The Social Insurance agency collaborates with mass media agencies to promote information dissemination and popularization of health insurance through various forms.

II. FOR HEALTH INSURANCE MEDICAL CARE FACILITIES

1. Prescribe the use of drugs, infusions, blood and blood products, biological items, consumables, perform procedures, surgeries, tests, and other medical services safely and reasonably according to the Ministry of Health's technical regulations. Strictly implement transfer regulations.

2. Create favorable conditions for Social Insurance agency staff stationed at the facility to carry out publicity and explanation work about health insurance, guide health insurance participants about their rights, responsibilities, and resolve complaints related to the medical care of health insurance cardholders;

3. Healthcare facilities have the responsibility to organize and monitor activities providing medical care for health insurance cardholders; statistically track and collect self-pay portions of hospital fees from health insurance cardholders, issue hospital fee receipts according to the regulations of the Ministry of Finance to patients.

4. Healthcare facilities have the responsibility to accurately and truthfully aggregate medical costs for health insurance cardholders to settle and reimburse promptly with the Social Insurance agency.

PART VI

IMPLEMENTATION

 1. The Ministry of Health shall be responsible for promulgating, amending, and supplementing the list of medicines, medical consumables, rehabilitation technical service items, and technical level classification in healthcare services as the basis for health insurance payment.

2. The Vietnam Social Security shall be responsible for:

a) Directing, guiding the implementation, and inspecting and evaluating the implementation of health insurance policies nationwide to report and propose timely solutions to competent authorities;

b) Inspecting and supervising employers in their compliance with health insurance contributions according to regulations, reporting to competent authorities for resolution in accordance with the law;

c) Developing annual plans for health insurance exploitation to send to the inter-ministerial body; implementing legal provisions and requirements of competent authorities regarding statistical systems, professional activity reports, financial statements, and inspections and audits.

3. People's Committees of provinces and centrally-administered cities shall be responsible for directing, organizing the implementation, inspecting, and auditing the execution of health insurance regulations and resolving difficulties in the implementation of health insurance policies at the local level.

4. Departments of Health of provinces and centrally-administered cities shall direct healthcare facilities to organize the implementation of policies ensuring healthcare services for individuals holding health insurance cards.

5. The Ministry of National Defense, after reaching consensus with the Ministry of Health and the Ministry of Finance, on the principle of fully ensuring rights and responsibilities under the Health Insurance Regulations issued together with Decree No. 63/2005/NĐ-CP dated May 16, 2005 of the Government, shall guide management and organization of health insurance for officials, civil servants, employees, and defense workers in military agencies, units, and enterprises, and for contractual laborers working in administrative military units and military enterprises stationed in strategic areas.

PART VII

IMPLEMENTING PROVISIONS

This Circular shall take effect fifteen days from the date of publication in the Official Gazette. Previous regulations that conflict with this Circular are hereby abolished.

During implementation, if there are difficulties or obstacles, they should be reported to the inter-ministerial body for consideration and resolution./.