Decree No. 58/1998/NĐ-CP Issuing the Social Health Insurance Regulation

DECREE OF THE GOVERNMENT
Issuing the Health Insurance Regulation

THE GOVERNMENT

Pursuant to the Government Organization Law dated September 30, 1992;

At the proposal of the Minister of Health,

DECREE:

Article 1. The Health Insurance Regulation is hereby issued together with this Decree.

Article 2. This Decree shall take effect 45 days from the date of signature. This Decree replaces Decree No. 299/HĐBT dated August 15, 1992 of the Council of Ministers (now the Government) on the Health Insurance Regulation and Decree No. 47/CP dated June 6, 1994 of the Government amending certain Articles of the Health Insurance Regulation.

Article 3. The Ministers of Health, Finance, Labor - War Invalids and Social Affairs, the Minister - Director of the Government Organizational Cadre Board shall be responsible for guiding the implementation of this Decree.

Article 4. The Ministers, Heads of ministerial-level agencies, agencies under the Government, and Chairpersons of Provincial People's Committees directly under the Central Government shall be responsible for implementing this Decree./.

HEALTH INSURANCE REGULATION

Issued together with Decree No. 58/1998/NĐ-CP dated August 13, 1998 of the Government.

PART I
GENERAL PROVISIONS

Article 1. Health insurance (BHYT) as defined in this Regulation is a social policy organized and implemented by the State to mobilize contributions from employers, employees, organizations, and individuals to cover medical expenses according to the provisions of this Regulation for persons holding health insurance cards when they are sick.

Article 2. Compulsory health insurance shall apply in the following cases:

1. Vietnamese workers working in:

a) State-owned enterprises, including those belonging to the armed forces;

b) Economic organizations under administrative and public service agencies, Party agencies, political and social organizations;

c) Foreign-invested enterprises, export processing zones, centralized industrial parks; foreign agencies, international organizations in Vietnam, except where international treaties to which the Socialist Republic of Vietnam is a party provide otherwise;

d) Non-state economic units with ten or more employees.

2. Civil servants working in administrative and public service agencies; persons working in Party agencies, political and social organizations; village, ward, town cadres receiving monthly living allowances as stipulated in Decree No. 09/1998/NĐ-CP dated January 23, 1998 of the Government; persons working in people-elected bodies from central to commune level.

3. Persons receiving retirement benefits or monthly social insurance allowances due to reduced work capacity.

4. Persons who have rendered meritorious service to the revolution as prescribed by law.

5. Social welfare beneficiaries who receive state funding through social insurance.

Article 3. Voluntary health insurance shall apply to all subjects who wish to participate in BHYT.

Article 4.

1. The BHYT Fund is formed from health insurance premiums and other sources.

2. The BHYT Fund is managed uniformly and used to pay for outpatient and inpatient medical expenses and management costs of the BHYT program.

3. Health insurance activities are exempt from taxation.

Article 5. The Vietnamese Health Insurance Agency is organized vertically and managed uniformly from central to local levels; it receives state funding to build physical and technical infrastructure; it implements measures to preserve and grow the BHYT Fund in accordance with the law.

PART II
HEALTH INSURANCE REGIME AND COST REIMBURSEMENT
MEDICAL EXAMINATION AND TREATMENT INSURANCE

Article 6. Persons holding compulsory health insurance cards are entitled to health insurance benefits when seeking outpatient and inpatient care, including:

1. Medical examination, diagnosis, and treatment;

2. Laboratory tests, X-ray examinations, functional tests;

3. Medicines listed in the Ministry of Health's directory;

4. Blood and fluid transfusions;

5. Procedures and surgeries;

6. Use of medical supplies, equipment, and hospital beds.

Article 7. Health insurance medical expenses are reimbursed at the following rates:

1. The BHYT Fund pays 80% of medical expenses based on hospital fees, with the remaining 20% paid by the patient to the healthcare facility. For beneficiaries of social preferential policies as stipulated in the Ordinance on Preferential Treatment for Revolutionary Activists, Martyrs and Their Families, War Invalids, Veterans, and Those Who Contributed to the Revolution, the BHYT Fund will pay 100% of medical expenses based on hospital fees;

2. If the amount that the patient pays for 20% of medical expenses in a year exceeds six months of the minimum wage, subsequent medical expenses in the year will be fully covered by the BHYT Fund.

Article 8. Persons holding health insurance cards can only enjoy health insurance benefits as stipulated in Article 7 of this Regulation when:

1. Seeking medical care at healthcare facilities registered on their card for health management and care;

2. Seeking medical care at other healthcare facilities referred by hospitals in accordance with the regulations on medical specialty levels set by the Ministry of Health;

3. Seeking emergency medical care at any state-run healthcare facility.

Article 9. In cases where patients seek medical care based on personal requests: choosing doctors, wards, healthcare facilities, and medical services; seeking medical care beyond the medical specialty level as prescribed by the Ministry of Health; seeking medical care at healthcare facilities without contracts with the health insurance agency, the BHYT Fund will only reimburse medical expenses based on hospital fees at appropriate medical specialty levels as prescribed by the Ministry of Health and as stipulated in Article 7 of this Regulation. Any additional costs (if any) must be paid by the holder of the health insurance card to the healthcare facility.

Article 10. The BHYT Fund will not reimburse in the following cases:

1. Treating leprosy; using drugs to treat tuberculosis, malaria, schizophrenia, epilepsy, family planning services (as these are already covered by the state budget);

2. Preventing and treating rabies; preventing diseases, testing, diagnosing, and treating HIV/AIDS, gonorrhea, syphilis;

3. Vaccination, convalescence, restorative care, health check-ups, infertility treatment;

4. Plastic surgery, prosthetic limbs, artificial eyes, dentures, glasses, hearing aids, artificial lenses, artificial joints, artificial heart valves;

5. Congenital diseases and congenital defects;

6. Occupational diseases, work-related accidents, traffic accidents, war injuries, and natural disasters;

7. Suicide, intentional injury, drug addiction, violation of the law.

Article 11. Health insurance medical expenses are reimbursed in two forms:

1. The health insurance agency reimburses healthcare facilities according to contracts.

2. The health insurance agency reimburses health insurance patients for medical expenses as stipulated in Articles 7 and 9 of this Regulation.

CHAPTER III
RESPONSIBILITIES, METHODS, AND AMOUNTS OF COMPULSORY HEALTH INSURANCE CONTRIBUTIONS

Article 12. The contribution amounts and responsibilities for compulsory health insurance are as follows:

1. The subjects specified in points a and b, Clause 1, Article 2 of this Regulation shall pay health insurance contributions at a rate of 3% of the salary grade, position, and retention differential coefficient (if any) recorded in the labor contract, and other allowances for area, hardship, position, and seniority, with the employer responsible for paying 2% and the employee paying 1%.

2. The subjects specified in points c and d, Clause 1, Article 2 of this Regulation shall pay health insurance contributions at a rate of 3% of the salary, wages, and allowances (if any) recorded in the labor contract in accordance with state regulations, with the employer responsible for paying 2% and the employee paying 1%.

3. The subjects specified in Clause 2, Article 2 of this Regulation:

a) For those receiving salaries: the health insurance contribution rate shall be 3% of the salary grade, position salary, retention differential coefficient (if any), and allowances for position, area, hardship, seniority, as prescribed by the State. The employing agency is responsible for paying 2%, while civil servants and public officials pay 1%.

b) For those receiving living expenses who are party cadres, administrative staff, mass organization staff, and social service personnel at communes, wards, and towns: the health insurance contribution rate shall be 3% of the living expenses and any allowances (if any). The agency providing living expenses pays 2%, while the recipient of living expenses pays 1%.

c) For those receiving living expenses who are incumbent People's Council deputies at all levels not included in the state establishment or not entitled to monthly social insurance benefits: the health insurance contribution rate shall be 3% of the current minimum wage, paid by the agency providing living expenses.

4. The subjects specified in Clause 3, Article 2 of this Regulation shall pay health insurance contributions at a rate of 3% of the pension or monthly social insurance allowance, directly paid by the social insurance agency.

5. The subjects specified in Clauses 4 and 5, Article 2 of this Regulation shall pay health insurance contributions at a rate of 3% of the current minimum wage, paid by the agency directly managing the financial resources of the subject.

6. The Ministry of Finance shall be responsible for balancing the budget to implement the mandatory health insurance regime for the subjects specified in points b and c, Clause 3, Article 12 of this Regulation from January 1, 1999.

Article 13. Method of Health Insurance Contribution Payment

1. Agencies, units, and employers specified in Clauses 1, 2, and 3, Article 12 of this Regulation shall deduct the health insurance contribution in advance and collect the health insurance contribution from employees according to the prescribed ratio to deposit into the health insurance fund at least once every three months.

2. Agencies and units managing the financial resources of the subjects specified in Clauses 4 and 5, Article 12 of this Regulation shall deposit the health insurance contribution into the health insurance fund on a quarterly basis.

3. Agencies, units, employers, and health insurance agencies may enter into contracts regarding the payment of contributions and issuance of long-term health insurance cards.

PART IV
RIGHTS AND RESPONSIBILITIES OF THE PARTIES TO HEALTH INSURANCE

Article 14.

1. The holder of a health insurance card has the right:

a) To receive medical examination and treatment under the health insurance regime as stipulated in Chapter II of this Regulation;

b) To choose one of the convenient primary healthcare facilities in their place of residence or workplace, as guided by the health insurance agency, for health management, care, and examination and treatment;

c) To change their registration for primary healthcare facilities at the end of each quarter;

d) To have hospitalization fees reimbursed under the health insurance regime when giving birth to the first and second child;

đ) To request the health insurance agency to ensure their rights as prescribed by this Regulation;

e) To lodge complaints with competent state authorities when the employer, health insurance agency, or medical facilities violate this Regulation.

2. The holder of a health insurance card has the responsibility:

a) To pay health insurance contributions fully and on time;

b) To present the health insurance card when seeking medical examination and treatment;

c) To keep and not lend the health insurance card to others.

Article 15.

1. Agencies, units, and employers have the right:

a) To refuse to comply with requests from the health insurance agency and medical facilities that are not in accordance with this Regulation;

b) To lodge complaints with competent state authorities when the health insurance agency or medical facilities violate the health insurance regulation. During the complaint period, they must still fulfill their obligation to pay health insurance contributions as prescribed by this Regulation.

2. Agencies, units, and employers have the responsibility:

a) To pay health insurance contributions in accordance with the provisions of the health insurance regulation;

b) To provide the health insurance agency with documents related to labor, salary, wages, and allowances concerning the payment and implementation of the health insurance regime;

c) To comply with inspections and audits regarding the implementation of the health insurance regime conducted by competent state authorities.

Article 16.

1. The health insurance agency has the right:

a) To require agencies, units, and employers to pay health insurance contributions and implement the health insurance regime, and to provide relevant documents concerning the payment and implementation of the health insurance regime;

b) To organize agents to issue health insurance cards;

c) To enter into contracts with legitimate medical facilities to provide medical examination and treatment services to insured persons;

d) To require medical facilities to provide medical records, case files, and other documents related to the reimbursement of health insurance examination and treatment costs;

đ) To refuse to reimburse examination and treatment costs that do not comply with the provisions of the health insurance regulation or do not conform to the terms of the contract signed between the health insurance agency and the medical facility;

e) To seize counterfeit documents and health insurance cards and transfer them to investigative authorities for handling in accordance with the law;

g) To recommend to competent authorities the handling of units and individuals violating the health insurance regulation.

2. The health insurance agency has the responsibility:

a) To collect health insurance contributions, issue health insurance cards, and guide the management and use of health insurance cards;

b) To provide information about medical facilities and guide participants in health insurance to select and register;

c) To manage the fund and reimburse health insurance costs in accordance with regulations and promptly;

d) To inspect and appraise the implementation of the health insurance regime;

đ) To organize information dissemination and promotion about health insurance;

e) To resolve complaints about the implementation of the health insurance regime within its jurisdiction.

Article 17.

1. Health insurance examination and treatment facilities have the following rights:

a) To request the health insurance agency to temporarily advance funds and reimburse examination and treatment costs in accordance with the health insurance regulation and the signed examination and treatment contract;

b) To provide medical examination and treatment and health services in accordance with professional principles;

c) To request the health insurance agency to provide data on health insurance cards registered at the medical facility;

d) To refuse to comply with requests outside the scope of the health insurance regulation and the signed contract with the health insurance agency;

e) To file complaints with competent authorities when the health insurance agency violates the examination and treatment contract.

2. Health insurance examination and treatment facilities have the following responsibilities:

a) To comply with the examination and treatment contract for health insurance.

b) Carry out the recording and provision of documents related to medical examination and treatment for persons covered by Health Insurance, serving as the basis for payment and resolution of disputes regarding Health Insurance;

c) Designate the use of medicines, biological materials, procedures, surgeries, tests, and other safe and reasonable healthcare services in accordance with the technical regulations of the Ministry of Health;

d) Create favorable conditions for health insurance agency staff stationed at the facility to conduct promotional and explanatory work on Health Insurance; inspect the protection of rights and resolve complaints related to medical examination and treatment for persons holding Health Insurance cards;

đ) Check Health Insurance cards, identify and report to Vietnam Health Insurance cases of violations and abuse of the Health Insurance system;

CHAPTER V
MANAGEMENT, USE OF FUNDS AND HEALTH INSURANCE CARDS

Article 18. The Health Insurance Fund is centrally managed and unified throughout the Vietnam Health Insurance system; it is independently accounted for outside the state budget and is protected by the State;

Article 19. Contributions to the Health Insurance Fund from mandatory participants are allocated and used as follows:

1. Allocate 91.5% to the medical examination and treatment fund, of which 5% is set aside for the medical examination and treatment reserve fund;

a) Any surplus in the medical examination and treatment fund in a year shall be transferred to the reserve fund;

b) In cases where the cost of medical examination and treatment exceeds the payment capacity of the medical examination and treatment fund in a year, it can be supplemented from the reserve fund;

2. Allocate 8.5% for the regular management expenses of the Vietnam Health Insurance system according to the annual budget approved by the competent authority and the state expenditure regulations;

3. Temporary idle funds of the Health Insurance Fund, if any, may be used to purchase treasury bills and government bonds issued by the State Treasury and state-owned commercial banks, and other measures may be taken to preserve and grow the Health Insurance Fund but must ensure the source of funds for payment when necessary;

The Ministry of Health and the Ministry of Finance shall issue financial management regulations for Vietnam Health Insurance;

Article 20.

1. Health Insurance Cards are issued by Vietnam Health Insurance;

2. Health Insurance Cards are valid for immediate and continuous use upon timely payment of Health Insurance premiums as prescribed;

3. Health Insurance Cards become valid for use thirty days after payment of Health Insurance premiums in the following cases:

a) First-time payment of Health Insurance premiums;

b) Continued payment of Health Insurance premiums after a period of interruption due to any reason;

Chapter VI
VOLUNTARY HEALTH INSURANCE

Article 21. Voluntary health insurance as stipulated in these Regulations aims to implement social policies in medical examinations and treatments, not for business purposes, and does not apply legal provisions on insurance business;

Article 22. Voluntary Health Insurance applies to all members of society, including foreigners working, studying, or traveling in Vietnam;

The Government encourages the expansion and diversification of voluntary Health Insurance schemes, while encouraging the Red Cross Society, charitable organizations, mass organizations, state-owned and private economic organizations to contribute to purchasing Health Insurance Cards for the poor. People's Committees at all levels are responsible for paying attention and creating favorable conditions for local residents to participate in voluntary Health Insurance;

Article 23.

1. Types of voluntary Health Insurance include:

a) Outpatient Health Insurance;

b) Inpatient Health Insurance;

c) Supplementary Health Insurance for mandatory Health Insurance;

d) Other types of voluntary Health Insurance;

2. Persons holding voluntary Health Insurance Cards are entitled to have their medical examination and treatment costs reimbursed by the Health Insurance Fund according to the level of contribution and type of voluntary Health Insurance chosen. If the voluntary Health Insurance premium is equivalent to the average mandatory Health Insurance premium in the region, the holder of a voluntary Health Insurance Card will enjoy Health Insurance benefits as stipulated in Chapter II of this Regulation;

The Ministry of Health and the Ministry of Finance shall establish a framework for contribution and benefit levels for voluntary Health Insurance; the Minister of Health shall provide detailed guidelines for contribution and benefit levels for voluntary Health Insurance applicable to each locality after consultation with the People's Committee of the province or centrally-administered city;

Article 24. Revenue from voluntary Health Insurance is separately accounted for and used for the following purposes:

1. Reimbursement of medical examination and treatment costs for holders of voluntary Health Insurance Cards as prescribed;

2. Expenses for agents collecting and issuing voluntary Health Insurance Cards;

3. Regular management expenses of the Health Insurance agency;

Vietnam Health Insurance is responsible for uniformly managing the voluntary Health Insurance Fund. The Ministry of Health and the Ministry of Finance shall specify details and guide the use of the voluntary Health Insurance Fund;

Chapter VII
ORGANIZATION AND MANAGEMENT OF HEALTH INSURANCE

Article 25. Vietnam Health Insurance was established based on the unification of health insurance agencies from central to local levels and sectoral health insurance to manage and implement health insurance policies under this Regulation;

Article 26. The Government assigns the Ministry of Health to perform the function of state management over Health Insurance. The content of state management includes:

1. Developing policies and laws on Health Insurance for submission to higher authorities for issuance or issuance within its authority;

2. Coordinating with the Ministry of Finance and the Chairman of the provincial or centrally-administered municipal People's Committee to guide the implementation of voluntary Health Insurance;

3. Guiding inspections and audits of the implementation of laws and regulations on Health Insurance;

Article 27. The Vietnam Health Insurance is organized and managed according to a centralized and unified system from central to local levels.

1. AT Central level: Vietnam Health Insurance is subordinate to the Ministry of Health;

2. AT Provincial level: Provincial and centrally-administered municipal Health Insurance and sectoral Health Insurance under Vietnam Health Insurance;

3. AT District level: Health Insurance branches under provincial and centrally-administered municipal Health Insurance;

Vietnam Health Insurance has the tasks and powers: to organize and implement the Health Insurance Charter; manage income and expenditure of the Health Insurance Fund nationwide; propose plans for the preservation and growth of the Health Insurance Fund and organize their implementation after approval; print, issue, and manage Health Insurance Cards; manage organizational structure, personnel, technical facilities throughout the Health Insurance agency system according to state regulations;

The organizational and operational regulations of Vietnam Health Insurance shall be issued by the Minister of Health after consultation with the Minister and the Director of the Civil Service Department of the Government;

Article 28. The Management Board of Vietnam Health Insurance is the supervisory body overseeing the activities of Vietnam Health Insurance;

The Management Board of Vietnam Health Insurance has the tasks and powers: to direct, supervise, and inspect the management, collection, and expenditure of the Health Insurance Fund; approve plans for balancing the Health Insurance Fund across the entire system; decide on measures to preserve and grow the Health Insurance Fund; approve annual budgets and final accounts of Vietnam Health Insurance; approve organizational plans, propose mergers, divisions, or dissolution of member units, and propose appointments or dismissals of the General Director of Vietnam Health Insurance;

The Management Board of Vietnam Health Insurance consists of a Chairperson, Deputy Chairpersons, and members.

The Chairman of the Management Board is a leader of the Ministry of Health appointed by the Prime Minister upon the proposal of the Minister of Health and the Minister, Head of the Civil Service Personnel Committee of the Government. Members are authorized representatives of the Ministries: Health, Finance, Labor - Invalids and Social Affairs, Vietnam General Confederation of Labor, and Vietnam Health Insurance.

The Minister of Health appoints the Vice Chairman of the Management Board and members of the Vietnam Health Insurance Management Board after reaching agreement with the aforementioned Ministries and sectors.

Article 29. Vietnam Health Insurance is managed and operated under the head system by the General Director. Assistant to the General Director are Deputy General Directors.

The Minister of Health appoints and dismisses the General Director of Vietnam Health Insurance upon the proposal of the Vietnam Health Insurance Management Board and agreement of the Minister, Head of the Civil Service Personnel Committee of the Government.

Deputy General Directors of Vietnam Health Insurance are appointed and dismissed by the Minister of Health upon the proposal of the General Director of Vietnam Health Insurance.

Provincial and centrally-administered city Health Insurance Directors and Sector Health Insurance Directors are appointed and dismissed by the General Director of Vietnam Health Insurance after obtaining opinions from the People's Committees of provinces and centrally-administered cities and sector leaders.

Chapter VIII
REWARD, DISPUTE SETTLEMENT AND VIOLATION HANDLING

Article 30. Agencies, units, and individuals with achievements in the health insurance cause shall be rewarded according to general regulations.

Article 31. When disputes arise regarding health insurance, they will be resolved by health insurance agencies at various levels, competent state management agencies, or courts, depending on the nature of the case, in accordance with the provisions of the law.

Article 32. Agencies, units, or individuals violating the provisions of this Charter shall be dealt with according to administrative penalty regulations in the field of health insurance, depending on the severity of the violation. If damage is caused, compensation for damages must be made in accordance with the provisions of the law./.