Circular No. 40/2015/TT-BYT stipulates registration for initial health check-ups and treatment under health insurance and referral for health check-ups and treatment under health insurance across commune, district, provincial, and central levels.

CIRCULAR

Regulations on registration for initial health insurance medical examination and treatment

and referral for health insurance medical examination and treatmentpolicies

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Pursuant to the Health Insurance Law No. 25/2008/QH12 dated November 14, 2008 and the Law Amending and Supplementing Certain Provisions of the Health Insurance Law No. 46/2014/QH13 dated June 13, 2014;

Pursuant to the Law on Diagnosis and Treatment No. 40/2009/QH12 dated November 23, 2009;

and cryptographic personnel

This Circular prescribes procedures for receiving, providing health care for domestic violence victims and statistical reports on domestic violence victims at medical facilities.

At the proposal of the Director of the Health Insurance Department, Ministry of Health;

The Minister of Health issues this Circular regulating registration for initial health insurance medical examination and treatment and referral for health insurance medical examination and treatment.

PART I

GENERAL PROVISIONS

Article 1. Scope of Regulation

This Circular stipulates the procedures for registration for initial health insurance medical examination and treatment and referral for health insurance medical examination and treatment.

Article 2. Principles

1. The primary health insurance medical examination and treatment registration facilities specified in this Circular shall be determined according to the levels within the state's medical examination and treatment facility system and equivalent facilities.

2. Individuals holding health insurance cards may be referred for medical examination and treatment in accordance with the regulations on technical referrals between medical examination and treatment facilities and the provisions of this Circular.

Chapter II

PRIMARY HEALTH INSURANCE MEDICAL EXAMINATION AND TREATMENT FACILITIES

Article 3. Primary health insurance medical examination and treatment facilities at the commune level and equivalent

1. Commune health stations, ward health stations, town health stations;

2. Outpatient clinics, health stations, health rooms of agencies, units, organizations;

3. Private independent family doctor outpatient clinics;

4. Military-civilian health stations, military-civilian outpatient clinics, military hospitals at battalion level and other medical examination and treatment facilities as prescribed by the Minister of National Defense.

Article 4. Primary health insurance medical examination and treatment facilities at the district level and equivalent

1. District general hospitals, district-level city general hospitals, provincial-level city general hospitals;

2. District health centers with medical examination and treatment functions; district health centers with outpatient departments;

3. Outpatient departments; regional outpatient departments;

4. General hospitals of Class III, Class IV, and unranked under Ministries and State Agencies or directly under units under Ministries and State Agencies;

5. Private general hospitals equivalent to Class III, equivalent to Class IV, or unranked equivalent;

6. Private traditional medicine hospitals equivalent to Class III, equivalent to Class IV, or unranked equivalent;

7. Health Departments, Hospital Departments directly under the Ministry of Public Security, Provincial Public Security Hospitals, Central Public Security Hospitals;

8. Military-civilian health centers, military hospitals, military-civilian hospitals, military hospitals of Class III, Class IV, or unranked, military-civilian hospitals of Class III, Class IV, or unranked, other medical examination and treatment facilities as prescribed by the Minister of National Defense.

Article 5. Primary health insurance medical examination and treatment facilities at the provincial level and equivalent

1. Provincial general hospitals, central city general hospitals;

2. General hospitals of Class I, Class II under Ministries and State Agencies, or directly under units under Ministries and State Agencies;

3. Specialized hospitals, specialized institutes, specialized centers, provincial central preventive health centers with outpatient departments;

4. Children's hospitals, provincial central children's and maternity hospitals;

5. Private general hospitals equivalent to Class I, equivalent to Class II;

6. Traditional medicine hospitals of provinces, centrally-administered cities, Ministries, and State Agencies;

7. Private traditional medicine hospitals equivalent to Class I, equivalent to Class II;

8. Outpatient departments under the Provincial Cadre Health Care and Protection Boards;

9. Class II hospitals under the Ministry of National Defense, Class II military-civilian hospitals, other medical examination and treatment facilities as prescribed by the Minister of National Defense.

Article 6. Primary health insurance registration examination and treatment bases at central level and equivalent

1. General hospitals under the Ministry of Health, except for those specified in Clause 3 of this Article;

2. Specialized hospitals and Institutes under the Ministry of Health with general outpatient departments;

3. Hospital of Friendship, Da Nang Central Hospital, and Thong Nhat Hospital under the Ministry of Health;

4. Special class hospitals, Class I hospitals under the Ministry of National Defense, Military Traditional Medicine Institute, and other medical examination and treatment facilities as prescribed by the Minister of National Defense.

Article 7. Conditions for primary health insurance registration examination and treatment bases

1. Medical examination and treatment facilities must have a permit to operate medical examination and treatment services.

2. Practitioners of medical examination and treatment must have a practice certificate for medical examination and treatment.

3. Medical examination and treatment facilities specified in Clauses 1, 2, and 4 of Article 3 of this Circular, if they do not yet have a permit to operate medical examination and treatment services, must meet the conditions regarding human resources, infrastructure, equipment, ensuring the ability to provide routine medical examination and treatment services and initial emergency care, and supply and distribute medicines within the scope of their professional activities as prescribed by laws on medical examination and treatment.

4. Independent family doctor clinics: Must meet the conditions prescribed by the Ministry of Health for issuing permits to operate independent family doctor clinics.

5. For general outpatient departments, there must be at least two (2) internal and surgical specialties; for general outpatient departments providing medical examination and treatment services for children, in addition to the two (2) specialties mentioned above, there must be a pediatric specialty.

Chapter III

REGISTRATION FOR PRIMARY HEALTH INSURANCE MEDICAL EXAMINATION AND TREATMENT

Article 8. Registration for primary health insurance medical examination and treatment at primary health insurance medical examination and treatment bases at commune and district levels

Participants in health insurance are entitled to register for primary health insurance medical examination and treatment (hereinafter referred to as primary medical examination and treatment) at one of the medical examination and treatment facilities specified in Articles 3 and 4 of this Circular, regardless of administrative boundaries, in accordance with their place of work, residence, and the capacity of the medical examination and treatment facility.

Article 9. Registration for primary health insurance medical examination and treatment at primary health insurance medical examination and treatment bases at provincial and central levels

1. Participants in health insurance may register for primary medical examination and treatment at one of the medical examination and treatment facilities specified in Clauses 1, 2, 3, 4, 5, 6, 7, and 9 of Article 5 and Article 6 of this Circular in the following cases:

a) Persons residing permanently or temporarily, or working in districts, towns, cities under provinces that do not have medical examination and treatment facilities specified in Articles 3 and 4 of this Circular, or where such facilities cannot meet the requirements for primary medical examination and treatment for health insurance participants as determined by the Director of the Provincial Health Department after consultation with the Director of the Social Insurance Office of the province or centrally administered city in writing;

b) Persons residing permanently or temporarily, or working in districts, towns, cities under provinces may register for primary medical examination and treatment at medical examination and treatment facilities specified in Clauses 1, 2, 3, 4, 5, 6, 7, and 9 of Article 5 and Article 6 of this Circular as determined by the Director of the Provincial Health Department after consultation with the Director of the Social Insurance Office of the province or centrally administered city in writing.

2. Participants in health insurance may register for primary medical examination and treatment at one of the medical examination and treatment facilities specified in Article 8, Clause 1 of Article 9 of this Circular, or at another health insurance medical examination and treatment facility in the following cases:

a) Individuals who fall under the category managed and protected for health according to Guidance No. 52 HD/BTCTW dated December 2, 2005 of the Central Organization Committee of the Party on adjusting and supplementing the categories of individuals eligible for medical examination and treatment at certain central-level healthcare facilities may register for primary medical examination and treatment at the Hospital of Friendship, Da Nang Central Hospital, Thong Nhat Hospital under the Ministry of Health, or other medical examination and treatment facilities specified in Article 5 (except Clause 4) and Clauses 1, 2, and 4 of Article 6 of this Circular;

b) Individuals who fall under the category managed and protected for health of provincial and municipal officials may register for primary medical examination and treatment at outpatient departments under the Provincial Health Protection and Care Board or at medical examination and treatment facilities specified in Clauses 1, 2, 3, 5, 6, 7, and 9 of Article 5 of this Circular;

c) Those who have rendered meritorious service to the revolution and those aged 80 years or older may register for primary medical examination and treatment at medical examination and treatment facilities specified in Clauses 1, 2, 3, 5, 6, 7, and 9 of Article 5, and Clauses 1, 2, and 4 of Article 6 of this Circular;

d) Children under six years old may register for primary medical examination and treatment at medical examination and treatment facilities specified in Clauses 1, 2, 4, and 5 of Article 5 of this Circular;

đ) Retired military personnel may register for primary medical examination and treatment at medical examination and treatment facilities specified in Clause 9 of Article 5 and Clause 4 of Article 6 of this Circular.

3. Participants in health insurance living on island communes and islands may register for primary medical examination and treatment at the most convenient medical examination and treatment facility on the mainland if there are no medical examination and treatment facilities specified in Articles 3, 4, 5, and 6 of this Circular on the island communes and islands.

Chapter IV

TRANSFER FOR PRIMARY HEALTH INSURANCE MEDICAL EXAMINATION AND TREATMENT

Article 10. Transfer for medical examination and treatment under health insurance

The transfer for medical examination and treatment under health insurance shall be carried out in accordance with Circular No. 14/2014/TT-BYT dated April 14, 2014 of the Ministry of Health on the transfer of technical specialties among medical examination and treatment facilities, except for certain specific cases implemented in accordance with Article 11 of this Circular.

Article 11. Cases determined to be within the designated level for medical examination and treatment under health insurance

1. A person holding a health insurance card who registers for initial medical examination and treatment at a commune-level medical facility, a multi-purpose clinic, or a district hospital is entitled to undergo medical examination and treatment under health insurance at a commune health station, a multi-purpose clinic, or a district hospital within the same province.

2. A person holding a health insurance card who registers for initial medical examination and treatment at a commune-level medical facility and is transferred to a district hospital, including district hospitals ranked Class I and Class II and provincial traditional medicine hospitals (in cases where the district hospital does not have a traditional medicine department).

3. A person holding a health insurance card who is transferred from a district hospital, including district hospitals ranked Class I and Class II and provincial general hospitals, specialized hospitals, and specialized institutes, to a provincial specialized center, provincial general hospital, or specialized hospital of the same or lower class.

4. Emergency cases:

a) Patients can be treated for emergency conditions at any medical facility. The doctor or nurse receiving the patient will assess and determine the emergency status and record it in the medical file or chart.

b) After the emergency treatment phase, the patient may be admitted for inpatient treatment at the facility that initially provided emergency care, or transferred to another facility for continued treatment based on professional requirements, or returned to the initial registered medical facility after stabilizing their condition.

5. In cases where a patient undergoing a transfer for medical examination and treatment has other accompanying diseases discovered or developed outside those listed on the referral form, the receiving medical facility shall provide medical examination and treatment for these diseases within its scope of expertise.

6. In cases where a health insurance participant travels, studies, works temporarily, or resides for less than 12 months in another locality, they are entitled to undergo medical examination and treatment at a medical facility in that locality equivalent to the level of the initial medical facility recorded on their health insurance card. If that locality lacks an equivalent healthcare facility, the health insurance participant may choose another medical facility that provides initial health insurance medical examination and treatment services.

Article 12. Use of Referral Forms and Appointment Cards in Medical Examination and Treatment under Health Insurance

1. Use of Referral Forms for patients with health insurance cards:

a) When a patient is referred to another medical facility, only the referral form issued by the direct transferring medical facility is required;

b) When a patient visits a medical facility that is not the initial health insurance medical facility and is subsequently referred to another medical facility, only the referral form issued by the direct transferring medical facility is required;

c) The referral form is valid for use within ten working days from the date of issuance;

d) For patients with health insurance cards suffering from specified diseases, disease groups, or cases eligible for referral forms as detailed in Appendix No. 01 attached to this Circular, the referral form remains valid until December 31 of the calendar year. If the patient is still undergoing inpatient treatment at the medical facility by December 31 of that year, the referral form remains valid until the end of the current inpatient treatment period.

2. Use of Appointment Cards: Each appointment card is valid for one use according to the time specified on the appointment card issued by the medical facility. The format of the appointment card for health insurance patients is stipulated in Appendix No. 02 attached to this Circular.

Chapter V

RESPONSIBILITIES FOR IMPLEMENTATION

Article 13. Responsibilities of the Department of Health

1. Take the lead and coordinate with the Social Insurance of the province/city under the central government, medical establishments under the Ministry of Health, and other ministries and sectors located within the administrative region to implement:

a) Determining, compiling, and announcing the list of medical establishments registered for primary healthcare services according to the levels on the provincial/city territory;

b) Guiding the registration for primary healthcare services for the subjects specified in Clause 3, Article 9 of this Circular;

c) Guiding the registration for primary healthcare services for children under six years old as stipulated in Point d, Clause 2, Article 9 of this Circular;

d) Guiding the transfer between medical establishments for insured patients in accordance with the regulations.

2. Take the lead and coordinate with the Social Insurance of the province/city under the central government, medical establishments under the Ministry of Health, and other ministries and sectors to define the subjects, subject group structure, and number of people participating in health insurance for primary healthcare services as prescribed in Articles 8 and 9 of this Circular, in accordance with the actual conditions of the locality and the capacity of the medical establishments.

3. Take the lead and coordinate with the Social Insurance of the province/city under the central government to guide the subjects, subject group structure, and number of people participating in health insurance for primary healthcare services at hospitals, centers, specialized hospitals, traditional medicine hospitals, ensuring compliance with the actual conditions of the medical establishments and organizing the system of medical establishments in the locality, making full use of human resources, facilities, equipment, scope of expertise, and quality of healthcare services.

4. Organize and direct the implementation of the provisions of this Circular for medical establishments under its management.

Article 14. Responsibilities of the Social Insurance of the province/city under the central government

1. Organize the signing of health insurance medical service contracts with medical establishments that meet the conditions for organizing primary healthcare services according to the list approved by the Department of Health.

2. Coordinate with the Department of Health to guide insured individuals to register or change their registration for primary healthcare services at medical establishments within the province/city under the central government in accordance with the provisions of this Circular.

3. Guide the provision of health insurance medical services for individuals holding health insurance cards as stipulated in Clause 6, Article 11 of this Circular.

Article 15. Responsibilities of Health Departments of Ministries and Sectors

1. Military Medical Service - Ministry of National Defense, Health Service - Ministry of Public Security:

a) Direct and guide medical establishments under the Ministry of National Defense and Ministry of Public Security that meet the conditions for organizing primary healthcare services to register with the local Department of Health;

b) Guide the implementation of registration for primary healthcare services and organization of health insurance medical services for medical establishments under the Ministry of National Defense and Ministry of Public Security.

2. Other Health Departments of Ministries and Sectors:

a) Direct medical establishments under the Ministry and Sector that meet the conditions for organizing primary healthcare services to register with the local Department of Health;

b) Guide the implementation of registration for primary healthcare services and organization of health insurance medical services in accordance with the regulations.

Article 16. Responsibilities of medical examination and treatment facilities

1. Conduct medical examinations, treatments, inter-facility referrals, and ensure benefits for insured persons according to regulations.

2. Based on the organizational conditions of the unit, the head of the medical examination and treatment facility assigns personnel responsible for promptly confirming the receipt of patients transferred during or outside regular working hours.

Chapter VI

IMPLEMENTING PROVISIONS

Article 17. Effective Date

1. This Circular takes effect from January 1, 2016.

2. Circular No. 37/2014/TT-BYT dated November 17, 2014, issued by the Minister of Health guiding registration for initial medical examinations and treatments and health insurance referral procedures shall cease to be effective from the date this Circular takes effect.

Article 18. Transitional Provisions

Insured persons who have registered for initial medical examinations and treatments at the facility indicated on their health insurance card before the date this Circular takes effect shall continue to receive initial medical examinations and treatments at that facility until there is a change in their initial medical examination and treatment registration, at which point they shall follow the guidance provided in this Circular.

Article 19. Cross-referencing Provisions

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

During the process of organizing and implementing, if there are difficulties or obstacles, it is recommended that agencies, organizations, and individuals reflect them to the Ministry of Health for consideration and resolution./.