Circular No. 39/2018/TT-BYT stipulates uniform prices for medical examination and treatment services under health insurance between hospitals of the same level nationwide and provides guidance on applying and settling costs for medical examination and treatment services under health insurance in certain cases.

Article 1. Scope of Regulation and Applicability

1. This Circular stipulates uniformly the prices of medical examination and treatment services covered by health insurance between hospitals of the same level nationwide and provides guidance on applying such prices and settling costs for medical examinations and treatments covered by health insurance in certain specific cases.

2. This Circular applies to healthcare facilities, units, organizations, and individuals involved in the process of medical examinations, treatments, and cost settlements under the health insurance scheme.

3. For medical examination and treatment services not reimbursed from the health insurance fund, the price framework and authority to set price levels shall be implemented in accordance with the Law on Prices, the Law on Medical Examination and Treatment, the Law on Local Administration Organization, and guiding documents for their implementation.

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 stipulated in this Circular are established based on direct costs and salaries to ensure medical examinations, patient care, treatment, and the provision of medical technical 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 and liquid); laundry, ironing, sterilization of textiles, examination tools; hygiene and environmental sanitation costs; disinfectants and anti-infection materials during medical examinations;

c) Maintenance and repair costs for buildings and equipment, procurement and replacement of assets, tools, and instruments such as air conditioners, computers, printers, dehumidifiers, fans, tables, chairs, beds, cabinets, lighting fixtures, and other necessary tools and instruments 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, bandages, cotton wool, gauze, saline solution, and other consumables for daily patient care and treatment (including costs for changing dressings for inpatients, except in cases paid outside the bed day service price as stipulated in Clause 5 and Clause 6, Article 7 of this Circular); electrodes, ECG cables, blood pressure cuffs, SpO2 cables during patient monitoring for intensive care unit beds;

Expenditures on medicines, blood, infusions, certain medical supplies (excluding those mentioned above); types of syringes, needles, drug extraction needles used in injections and infusions; infusion tubes, connectors, syringe pump cables, infusion machine cables used in injections and infusions; oxygen, oxygen breathing tubes, oxygen masks (except in cases where patients are prescribed mechanical ventilation services) are not included in the bed day service price structure and are settled according to actual usage for patients.

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, infusions, chemicals, consumables, replacement materials used in the provision of medical services and techniques;

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) Salary grades, positions, allowances, and contributions as prescribed by the State for public institutions and the basic salary level as stipulated in Decree No. 72/2018/ND-CP dated May 15, 2018 of the Government regarding the basic salary level for civil servants, officials, employees, and military personnel;

b) Standby allowance, surgical and procedural allowance pursuant to Decision No. 73/2011/QD-TTg dated December 28, 2011 of the Prime Minister on special allowances for civil servants, officials, employees, and workers in public healthcare facilities and epidemic prevention 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 socio-economic conditions;

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

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

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

6. Settlement of costs for medical examinations and treatments between the social insurance agency and healthcare facilities according to the service prices stipulated in this Circular and expenditures on medicines, chemicals, medical supplies not included in the service price structure (specifically noted in each service), blood, and blood products shall follow the principles stipulated in Article 24 of Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government detailing and guiding measures to implement certain provisions of the Law on 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 norms issued by competent authorities, prices of cost factors, actual cost levels, reasonably in accordance with current regulations and policies, ensuring average and advanced standards, meeting service quality requirements. Economic and technical norms serve as the basis for establishing service examination and treatment prices, and shall not be used as grounds for payment for specific examination and treatment services (except for certain special cases stipulated in Clause 6 of Article 5, Clause 16 of Article 6, and Clause 8 of Article 7 of this Circular). During implementation, if there are any norms that are inappropriate, units and localities shall report to the Ministry of Health for review and adjustment of norms and prices to ensure appropriateness.

Article 4. Principles for applying service prices to healthcare facilities that have signed health insurance examination and treatment contracts

1. Hospitals with beds, health centers with functions of examination and treatment, licensed to operate under the form of hospitals; district health centers with functions of examination and treatment, ranked as hospitals: apply the price level of hospitals of equivalent 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. Examination and treatment facilities not yet classified; military outpatient clinics, military-civilian outpatient clinics, military infirmaries; private general and specialized outpatient clinics: apply the price level of Grade IV hospitals.

4. For regional multi-specialty clinics:

a) In case of being granted a license to operate a hospital or falling within the cases prescribed in Clause 12 of Article 11 of Decree No. 155/2018/NĐ-CP dated November 12, 2018 of the Government amending and supplementing certain provisions related to investment conditions under the management of the Ministry of Health: apply the price level of Grade IV hospitals;

b) In case of only performing emergency tasks, outpatient examination and treatment: apply the price level of Grade IV hospitals. For cases where the Department of Health decides to have bed retention: apply a price equal to 50% of the daily ward price of Grade III internal medicine wards of Grade IV hospitals. The maximum number of days to be reimbursed is 03 days/person/treatment session. No reimbursement for examination fees when bed retention fees at the health station have been paid.

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

a) Outpatient examination fee: shall apply the price level of commune health stations. Technical service fees shall be 70% of the technical service fees listed in Appendix III.

b) For health stations decided by the Department of Health to have bed retention: apply a price equal to 50% of the daily ward price of Grade III internal medicine wards of Grade IV hospitals. The maximum number of days to be reimbursed is 03 days/person/treatment session. No reimbursement for examination fees when bed retention fees at the commune health station have been paid.

6. In case the patient has a health insurance card but uses examination and treatment services according to demand, the reimbursement of examination and treatment costs under health insurance shall be implemented in accordance with the provisions of point a, Clause 1 of Article 20 of Decree No. 85/2012/NĐ-CP dated October 15, 2012 of the Government on the mechanism of operation, financial mechanism for public health institutions and the price of examination and treatment services of public health institutions.

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

1. In case the patient comes to the outpatient department for examination and is then referred to inpatient treatment according to professional requirements, the payment for examination fees shall be implemented in accordance with the provisions of Clause 3 of this Article. In case the patient does not register for examination at the outpatient department but comes for inpatient treatment at clinical departments according to professional requirements, no payment for examination fees will be made.

2. Examination and treatment facilities organizing specialty examinations at clinical departments, patients registering for examination at the outpatient department and specialty examinations at clinical departments shall be considered as having undergone examination at the outpatient department. The calculation of the number of examinations and pricing shall be carried out in accordance with the provisions of Clause 3 of this Article.

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

4. Patients who come to the outpatient department for examination, have been examined and prescribed medication for home treatment, but later show abnormal symptoms and return to the same facility for immediate re-examination on the same day shall be considered as the second examination onwards in one day. Payment shall 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 human resources and examination tables according to demand to ensure the quality of outpatient examinations. For examination tables with more than 65 examination sessions/day, the social insurance agency shall only reimburse 50% of the examination fee from the 66th examination session onwards of that table. Within a maximum period of one quarter, if the healthcare facility still has examination tables with more than 65 sessions/day, the social insurance agency will not reimburse examination fees from the 66th session onwards of that 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 bed days for payment of hospitalization fees:

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

- In the case where a seriously ill patient undergoing inpatient treatment has not improved, died, or worsened, but the family requests discharge or transfer to a higher-level facility;

- In the case where a patient who has been treated at a higher-level facility through emergency care still requires continued inpatient treatment and is transferred back to a lower-level facility or to another medical facility;

b) The number of inpatient treatment days equals the discharge date minus the admission date: applicable to all other cases.

c) In the case where the patient enters and leaves the hospital on the same day (or enters the previous day and leaves the next day) with a treatment time of over 04 hours but less than 24 hours, it shall be counted as one day of treatment. In the case where the patient enters the emergency department without going through the outpatient department, with an emergency treatment time of 04 hours or less (including cases of discharge, admission, transfer, or death), examination fees, drug costs, medical supplies, and technical service fees shall be reimbursed, but no bed fee for intensive care emergency shall be reimbursed.

d) In the case where the patient enters and leaves the hospital with a treatment time of 04 hours or less, examination fees, drug costs, medical supplies, and technical service fees used by the patient shall be reimbursed, but no inpatient bed fee shall be charged.

2. In the same day, if the patient transfers between two departments, each department shall only be counted as half a day. If the patient transfers among three or more departments in the same day, the bed price for that day shall be calculated as the average of the highest priced bed price at the department with a stay of over 04 hours and the lowest priced bed price at the department with a stay of over 04 hours.

3. The maximum price for an orthopedic bed day or burn bed day shall not exceed ten days following a single surgery. From the eleventh day after surgery onwards, the price for an internal medicine bed day as specified in Section 3 of Appendix II attached to this Circular shall be applied.

4. The bed day price is calculated for one person per bed. In cases where two people share one bed at the same time, only half of the price shall be paid; if three or more people share one bed, only one-third of the treatment bed day price shall be paid.

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

a) For special-class hospitals, Class I or Class II hospitals that have established intensive care units, detoxification departments or centers, or combined intensive care and detoxification departments, which meet all conditions for operation as stipulated in Decision No. 01/2008/QĐ-BYT dated January 21, 2008 of the Minister of Health on the issuance of emergency, intensive care, and detoxification regulations (hereinafter referred to as Decision No. 01/2008/QĐ-BYT).

b) In cases where healthcare facilities have not established intensive care units but have beds in emergency departments or anesthesia recovery departments used for intensive treatment; postoperative beds for special surgeries and these beds meet the requirements for intensive care unit beds as stipulated in Decision No. 01/2008/QĐ-BYT.

c) Patients lying in these beds must be cared for, treated, and monitored according to emergency, intensive care, and detoxification regulations. Other cases shall only apply the price for intensive care unit beds and other types of beds as specified in Appendix II attached to this Circular.

6. For clinical departments with intensive care unit beds (for example, pediatric departments with pediatric intensive care unit beds, neonatal departments, or specialized care for premature infants): the price for intensive care unit bed days as specified in service number 2 of Appendix II attached to this Circular shall be applied.

7. Hospitals classified as Class III, Class IV, or unranked but approved by competent authorities to perform special surgeries: the highest orthopedic bed day price of the hospital providing the service shall be applied.

Example: At Hospital A, which has been approved to perform special surgeries: If the hospital is classified as Class III, it shall apply the orthopedic bed day price after Class I surgery for Class III hospitals; if the hospital is classified as Class IV or unranked, it shall apply the orthopedic bed day price after Class I surgery for 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 of the Minister of Health on the classification of surgeries, procedures, and staffing levels for each surgery or procedure (hereinafter referred to as Circular No. 50): the lowest surgery classification price for orthopedic bed days or burn bed days as specified in this Circular shall be applied.

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 price for orthopedic bed days or burn bed days based on the surgery classification as specified in Circular No. 50 shall be applied.

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 traditional medicine hospitals directly under the Ministry of Health classified as Class I: the bed day prices shall be applied according to the corresponding departments and bed types of Class I hospitals, without applying the prices of specialized hospitals directly 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-disciplinary format: apply the daily bed rate for the lowest-priced internal medicine specialty among the corresponding departments based on the hospital's classification level.

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

15. In cases where patients lie on stretchers or foldable beds: apply a price equal to 50% of the daily bed rate specified for each type of specialty as detailed in Appendix II attached hereto.

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

a) Actual number of beds used 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, foldable beds, double-bedded: two treatment bed days equal one converted bed day; triple or more bedded: three treatment bed days equal one converted 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 usage ratio per quarter (hereinafter referred to as bed usage ratio) by dividing the actual number of beds used in the quarter by the actual number of beds used in 2015 (the year before the direct referral system was implemented) multiplied by 100%. In cases where the actual bed usage ratio is calculated as described 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, renovation, expansion, or upgrade projects into use but have not yet received approval from competent authorities to increase bed numbers: the Department of Health and the social insurance agency shall agree on the additional bed numbers in this area to be added to the previously allocated planned bed numbers for payment settlement as stipulated in this clause.

Article 7. Application of prices and payment conditions for certain special technical services

1. Medical technical services shall be implemented 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 in the appendices attached to this Circular but classified equivalently in terms of technology and cost: shall be applied according to the price of technical services classified equivalently by the Ministry of Health in terms of technology and cost.

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 of 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 technology and cost) without specified prices: healthcare facilities shall develop cost standards, pricing plans, propose prices, and report to the Ministry of Health for examination and determination of prices.

3. For technical services that have been approved by the competent authority (ministries or central agencies for units under central management, Department of Health for units under local management) in the list of technical services (excluding care services already included in the treatment bed cost, and services that are part of another service's cost); for technical services that were ordered but could not be continued due to the patient's 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 as prescribed by law.

4. In cases where multiple interventions are performed during the same 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 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; 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 dressings in cases of laparoscopic surgery, routine wound dressing changes, or newborn umbilical cord dressing changes.²; 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; 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 dressings in cases of laparoscopic surgery, routine wound dressing changes, or newborn umbilical cord dressing changes.

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 immunological cross-matching tests at 37°C using anti-globulin serum (indirect Coombs test) in blood transfusions: payment shall be made according to the price of the service "Cross-matching with anti-human globulin" with code number 1340 or 1341 in Appendix III.

8. The quarterly settlement of certain technical services such as: conventional X-ray, digital X-ray (for diagnosis), CT scan up to 32 slices (for diagnosis, service code numbers 42, 43 in Appendix III), ultrasound (service code numbers 1, 2 in Appendix III), MRI (service code numbers 67, 68 in Appendix III) between health insurance authorities and healthcare facilities shall be carried out as follows:

a) Determine the maximum number of cases that the social health insurance agency will pay according to the price specified in this Circular by dividing the average number of cases according to the pricing standard by 8, then multiplying the result by the actual working hours of the unit, then multiplying by the actual working days in the quarter, then multiplying by the actual number of machines in operation at the healthcare facility in the quarter, and finally multiplying by 120%.

b) Pricing standard (number of cases per machine per 8-hour working day): Ultrasound service is 48 cases; Conventional X-ray and Digital X-ray services are 58 cases; CT Scan up to 32 slices is 29 cases; 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 cases where the number of cases proposed for payment exceeds the maximum number calculated as per point a of this clause: For the number of cases equal to the maximum number calculated as per point a of this clause, the social health insurance agency will pay according to the price specified in this Circular. For the number of cases exceeding the maximum number calculated as per point a of this clause, the social health insurance agency will pay according to the price excluding salary costs, with the specific payment price 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 operational X-ray machines, with actual working hours of 9 hours (1 extra hour per day); the healthcare facility organized outpatient services on Saturdays in Quarter III/2018 for 92 days, with 78 working days in the quarter.

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, assuming it is 20,000 cases, the health insurance agency will pay 18,322 cases according to the price specified in this Circular; the remaining 1,678 cases (= 20,000 cases - 18,322 cases) will be paid by the health insurance agency at 85% of the price specified in this Circular.

9. The provisions in Clause 8 of this Article, Clause 6 of Article 5, and Clause 16 of Article 6 of this Circular shall only apply to payments between the social health insurance agency and healthcare facilities, and shall not be applied to calculate the co-payment costs for patients.

10. During natural disasters or epidemics: the social health insurance agency will pay healthcare facilities based on the actual price and quantity of services provided, without applying the payment regulations stipulated in Clause 8 of this Article, Clause 6 of Article 5, and Clause 16 of 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; Departments of Health of provinces and centrally-administered cities shall aggregate and report to the provincial People's Committees to continue ensuring the budget according to the budget classification and current regulations on sources for implementing salary policy reforms 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 implement salary reform policies as currently prescribed by the Government regarding the basic salary for officials, civil servants, employees, and armed forces personnel.

2. In cases where the revenue of the unit does not ensure regular operations, the unit classified by the competent authority as a public service organization self-financing part of its regular expenses or a public service organization fully financed by the state for regular expenses: the unit will continue to receive state budget support for the shortfall in regular expenses to ensure employee benefits and normal operations of the unit 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 unified contact point with relevant departments of the Ministry of Finance to review, adjust, and promptly supplement the prices of medical examination and treatment services when adding factors forming the price according to the schedule, state adjustments to salary policies, economic-technical standards, or changes in the costs of factors forming the price.

- 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 Medical Examination and Treatment Management Department serves as the lead, coordinating with relevant departments and units to direct medical examination and treatment facilities to strictly implement professional regulations, comprehensively implement measures to improve service quality; organize inspections, audits, and supervision of professional activities related to service and drug prescription, material usage, inpatient admission, and other professional activities.

c) The Health Insurance Department serves as the lead, coordinating with relevant departments, the Inspectorate, and related units to organize inspections, supervision, or directing Provincial Health Departments and health management agencies of ministries and sectors to organize inspections and supervision of medical examination and treatment facilities, related units and organizations in implementing the provisions of this Circular.

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

2. Responsibilities of the Vietnam Social Security:

a) Implement this Circular, instruct social insurance agencies at all levels to promptly settle 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 instruct social insurance agencies at all levels to inform provincial people's committees, provincial health departments, and health management agencies under ministries and sectors about cases where services, medications, and supplies are used excessively or where patients are improperly admitted for inpatient treatment.

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 service demands and improve the quality of medical examination and treatment services for the public.

4. Responsibilities of healthcare facilities:

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

Article 11. Implementation Provisions

1. This Circular takes effect from January 15, 2019. Specifically, the service examination and treatment fees based on the minimum wage stipulated in Government Decree No. 72/2018/NĐ-CP mentioned in Appendices I, II, and III of this Circular will be applied from December 15, 2018.

2. Circular No. 15/2018/TT-BYT dated May 30, 2018, issued by the Ministry of Health, which unifies examination and treatment service fees for health insurance between hospitals of the same grade nationwide and provides guidance on applying and settling costs for examination and treatment under health insurance in certain situations, will cease to be effective from the date this Circular takes effect.

Article 12. Transitional Provisions

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

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./.