Joint Circular No. 77/2003/TTLT-BTC-BYT guides the implementation of voluntary health insurance

JOINT CIRCULAR

Guidelines for Voluntary Health Insurance

 

Pursuant to Decree No. 58/1998/NĐ-CP dated August 13, 1998 of the Government promulgating the Social Health Insurance Regulations (SHIR);
Pursuant to Decree No. 100/2002/NĐ-CP dated December 6, 2002 of the Government stipulating the functions, tasks, powers, and organizational structure of the Vietnam Social Security;
Pursuant to Decision No. 02/2003/QĐ-TTg dated January 2, 2003 of the Prime Minister on the issuance of the Financial Management Regulation for the Vietnam Social Security.
The Ministry of Finance and the Ministry of Health jointly issue the following guidelines for implementing voluntary social health insurance as follows:

I. GENERAL PROVISIONS

1. The voluntary social health insurance prescribed in this circular aims to implement social policies in medical examination and treatment (MET), not for business purposes, and does not apply the provisions of laws on insurance business.

2. Vietnamese citizens (excluding those with mandatory health insurance cards, health insurance cards issued under government social policies) all have the right to participate in voluntary health insurance based on the principle of collective and community solidarity to receive healthcare services.

3. Rights and obligations of participants in voluntary health insurance are uniformly implemented throughout the country. The premium rate for voluntary health insurance is determined based on the framework price of medical services, economic and social conditions, access to medical services, and the ratio of participants in each group.

4. The self-funded MET fund is centrally managed, uniformly accounted for as a separate component fund independent from the state budget and protected by the state according to the law. In cases where the self-funded MET fund is insufficient to cover expenses, it will be adjusted from other component funds according to Decision No. 02/2003/QĐ-TTg dated January 2, 2003 of the Prime Minister on the financial management regulations for the Vietnam Social Security.

II. FORMS OF ORGANIZATION OF VOLUNTARY SOCIAL HEALTH INSURANCE

1. Voluntary social health insurance is organized and implemented according to administrative boundaries and by target groups, specifically:

1.1. According to administrative boundaries: applicable to households, organized at the commune, ward, town level.

1.2. By target groups, applicable to:

- Students and trainees currently studying at educational institutions within the national education system;

- Members and affiliates of mass organizations, people's associations, trade unions... (hereinafter referred to collectively as Associations, Mass Organizations);

2. The Vietnam Social Security stipulates the minimum number of participants required for mobilization in each target group to ensure the principles of collective and community solidarity.

III. FRAMEWORK AND LEVELS OF CONTRIBUTIONS FOR VOLUNTARY SOCIAL HEALTH INSURANCE

1. Framework of contributions for voluntary social health insurance:

1.1. The framework of contributions for voluntary social health insurance is determined by region and per capita:

a. Regional classification:

- Urban areas: Central districts of cities directly under the central government; wards of cities and towns belonging to provinces;

- Rural areas: All remaining regions;

b. The contribution framework for one person for one year according to the region is as follows:

Unit of measurement: VND/person/year

1.2. To encourage more members of a household to join voluntary social health insurance, starting from the second member, each additional member joining voluntary social health insurance will have their contribution reduced by 5% compared to the first member's contribution (members in the family are those individuals within the same household registration who are eligible to join voluntary social health insurance by administrative boundary).

1.3. Voluntary social health insurance by target group: The contribution framework is determined for each individual participating in voluntary social health insurance.

1.4. Based on the contribution framework for social health insurance stipulated in this circular, upon the proposal of the Social Security of the province or centrally-administered city, the Vietnam Social Security decides on specific contribution levels after obtaining the agreement of the Ministry of Finance.

1.5. When the state-prescribed hospital fee schedule increases by 10% or more, if the voluntary social health insurance contribution has reached the maximum level of the contribution framework and the self-funded MET fund cannot balance the payment capacity, the Vietnam Social Security reports to the relevant ministries for adjustment of the contribution framework for voluntary social health insurance to be appropriate.

2. Methods of paying voluntary social health insurance contributions:

2.1. For those by administrative boundary: Directly register to participate and pay social health insurance contributions at least once every six months to the collection agent at the commune, ward, or town.

2.2. For students and trainees: Register to participate by class and school and pay social health insurance contributions at least once every six months to the collection agent at the school.

2.3. For members of associations, mass organizations, and trade unions: The associations, mass organizations, and trade unions prepare lists, collect money, and directly pay social health insurance contributions to the Social Security agency at least once every six months.

Encourage all levels of government, agencies, units, and charitable organizations to cooperate in mobilizing and supporting part of the funding for voluntary social health insurance participation or purchasing health insurance cards to give to individuals in need in the community.

IV. RIGHTS AND METHODS OF PAYING MEDICAL EXPENSES UNDER VOLUNTARY SOCIAL HEALTH INSURANCE

1. Rights of participants in voluntary social health insurance:

1.1. After paying social health insurance, participants in voluntary social health insurance are issued a health insurance card valid for the corresponding period of payment;

1.2. Individuals with health insurance cards are admitted, examined, treated, and entitled to social health insurance benefits as follows:

a. Primary health care:

- Primary health care services for holders of voluntary health insurance cards include the following contents:

+ Guidance on personal hygiene, nutritional hygiene, environmental hygiene, and disease prevention;

+ Health check-ups and management of personal health records;

+ Implementation of emergency first aid for accidents and sudden illnesses;

- Responsible bodies for primary health care:

+ Students and trainees receive primary health care at the school health office. If there is no health office at the school, the Social Security agency is responsible for contracting with the nearest health facility to ensure convenient and appropriate care;

+ Other groups receive primary health care at commune health stations.

Costs for primary health care at the aforementioned health facilities are covered by the Social Security agency, and holders of health insurance cards do not need to pay any amount.

b. Outpatient and inpatient care:

- Participants in the Health Insurance Program may choose a district or county healthcare facility to register for medical services. When the condition exceeds the professional and technical capacity of the healthcare facility, the participant will be referred to a higher-level facility with more advanced professional and technical capabilities.

- Holders of health insurance cards who receive medical care according to the prescribed level (district, provincial, central) shall have the Health Insurance Fund cover 80% of the costs, while the cardholder pays 20%. However, if the amount paid exceeds 1.5 million VND per year for outpatient and inpatient treatment, the Social Security Agency will reimburse the excess amount. In cases where the cost of a single outpatient visit is less than 20,000 VND, the cardholder does not need to pay 20%.

- Holders of health insurance cards when receiving outpatient and inpatient care are entitled to the following benefits:

+ Conducting examinations, tests, X-rays, functional diagnostic procedures as directed by physicians for diagnosis and treatment purposes;

+ Receiving medications from the list prescribed by the Ministry of Health, blood transfusions, intravenous fluids as directed by treating physicians, and using common consumable medical supplies and equipment for medical services;

+ Performing minor surgical procedures and surgeries;

+ Using hospital beds.

- If holders of health insurance cards seek medical care at facilities other than those registered on their cards, they must pay all medical expenses themselves. Subsequently, the Social Security Agency will review the case and reimburse part of the expenses, but not exceeding 80% of the average medical costs at the appropriate level of professional and technical expertise.

- In emergency situations, holders of health insurance cards can receive medical care at any state-owned healthcare facility and still enjoy health insurance benefits.

1.3. Women participating in voluntary health insurance are entitled to medical examination and treatment benefits as stipulated in this Circular. For maternity benefits, the Social Security Agency will only cover costs if the cardholder has participated voluntarily for at least 270 days.

1.4. Individuals who have continuously participated in voluntary health insurance for at least 24 months are eligible for reimbursement of medical expenses for certain special cases at the following rates:

- Heart surgery: up to 10 million VND per person per year;

- Dialysis: up to 12 million VND per person per year;

- Vaccinations: tetanus, animal bites, maximum 300,000 VND per person per year;

- Death benefit: 1,000,000 VND per case.

1.5. Cases not covered by the voluntary health insurance fund include:

- Treatment for leprosy, schizophrenia, epilepsy;

- Specialized drugs for tuberculosis, malaria;

- Family planning services;

- Assisted reproductive technologies;

- Organ transplantation;

- HIV/AIDS testing and treatment costs;

- Preventive vaccinations, convalescence, rehabilitation, regular health check-ups (including pre-employment health checks...);

- Cosmetic and reconstructive plastic surgery, artificial replacement materials;

- Rehabilitation treatments outside the scope defined by the Ministry of Health;

- Congenital diseases and congenital malformations;

- Occupational diseases;

- Traffic accidents, including residual effects of traffic accidents;

- War injuries;

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

- Early pregnancy testing, infertility treatment;

- Transportation costs for patients, meals during treatment;

2. Payment methods for medical expenses:

2.1. The Social Security Agency enters into contracts with healthcare facilities and pays medical expenses based on the partial hospital fee schedule set by the government, specifically:

- Outpatient medical care: Reimburse 80% of actual expenditures within the allocated budget quota as specified in Point 2.1, Section 2, Part VI of this Circular.

- Inpatient medical care: Pay actual expenditures based on the partial hospital fee schedule established by the government and guidelines issued by the Ministry of Health, after deducting 20% of patient payments from the total number of inpatients.

To enhance patient benefits and improve management efficiency, the relevant ministries permit the Social Security Agency to negotiate and agree with healthcare facilities to pilot payment methods such as capitation, case-based payments, or daily inpatient payments for insured patients.

2.2. Payment to holders of health insurance cards: The Social Security Agency directly reimburses medical expenses for holders of health insurance cards in the following circumstances:

- Voluntary participants in health insurance who have paid 20% of medical expenses exceeding 1.5 million VND in a year;

- Voluntary participants in health insurance who receive medical care outside the prescribed level or according to personal requests;

- Death benefits;

- Other special cases.

2.3. Procedures for paying voluntary health insurance medical expenses are guided by the Vietnam Social Security.

V. RESPONSIBILITIES OF THE PARTIES IN IMPLEMENTING VOLUNTARY HEALTH INSURANCE

1. For the Social Security Agency:

- Promote, guide, explain, and provide information about rights, responsibilities, and coverage of medical expenses for voluntary health insurance participants;

- Discuss and sign healthcare contracts with healthcare facilities. Fulfill all commitments made under signed contracts with healthcare facilities and voluntary health insurance cardholders;

- Implement fee collection, card issuance, and management of voluntary health insurance participants;

- Carry out verification work to ensure the rights of voluntary health insurance participants. Timely settle medical expenses according to regulations. Refuse to pay for medical expenses that do not comply with this Circular;

- Coordinate with healthcare facilities to resolve complaints related to the legitimate rights of voluntary health insurance participants;

- Regularly assess the use of voluntary health insurance funds, promptly propose measures to better protect patient rights, fund payment capacity, and prevent misuse of voluntary health insurance funds.

2. For healthcare facilities:

- Discuss and select payment methods and sign healthcare contracts with the Social Security Agency, ensuring conditions for contract implementation and protecting the rights of voluntary health insurance participants.

- Organize reception, guidance, and cooperate with representatives of the Social Security Agency stationed at hospitals (if applicable) to verify health insurance cards, preventing patients from using others' health insurance cards for medical care.

- Provide medical care in accordance with professional regulations. Cooperate with the Social Security Agency to manage voluntary health insurance patients during their hospital stay.

- Organize cost statistics for medical treatment under health insurance to serve settlement and finalization with the Social Insurance Authority, and collect 20% of the medical treatment costs of those holding health insurance cards.

- Coordinate with the Social Insurance Authority to respond and resolve complaints from those holding health insurance cards.

3. Voluntary health insurance participants:

- Register for voluntary health insurance according to the form issued by the Vietnam Social Insurance.

- Pay the full voluntary health insurance premium on time as agreed with the Social Insurance Authority.

- Carefully keep the health insurance card, do not erase, deface, or add information to it without authorization, and do not lend it to others. Present the health insurance card immediately when seeking medical treatment; in emergency cases, present the card within 48 hours to be eligible for health insurance benefits at the hospital where the emergency treatment was provided.

- Follow doctors' instructions and prescriptions.

- In cases of medical treatment outside the designated level, those holding health insurance cards must gather valid invoices and documents for direct payment to the Social Insurance Authority.

- Report to the Social Insurance Authority about the situation of medical treatment when their legitimate rights are violated.

VI. MANAGEMENT AND USE OF THE VOLUNTARY MEDICAL TREATMENT FUND

1. The voluntary medical treatment fund is formed from:

- Revenue from issuing voluntary health insurance cards;

- State support;

- Income from implementing measures to preserve and increase the voluntary medical treatment fund;

- Revenue from donations and aid from organizations and individuals both domestically and internationally;

- Other lawful revenues (if any).

2. Allocation and use of the voluntary medical treatment fund:

The voluntary medical treatment fund is centrally managed by the Vietnam Social Insurance and allocated annually as follows:

- 90% for medical treatment expenses;

- 8% for agent commissions for collecting and issuing health insurance cards.

- 2% for supplementary publicity work.

2.1. Allocation and use of funds for outpatient medical treatment expenses:

a. Outpatient medical treatment expenses for household members and associations:

- 50% transferred to the medical facility where the insured person has registered for medical treatment, specifically:

+ The medical facility receiving the aforementioned amount must transfer at least 10% to health stations in communes, wards, and towns where the insured person resides (in the form of medicine and consumable medical supplies) to provide initial healthcare services to insured persons at the primary level.

+ The remaining amount is used to pay for outpatient medical treatment expenses of insured persons within the designated level, payments for cases where patients are referred to higher levels, and emergency cases outside the designated level.

- The remaining 50% is managed by the Social Insurance Authority to pay for inpatient medical treatment expenses at medical facilities and direct payments to patients in cases of self-selected treatment, excess payments exceeding 1.5 million VND, and death benefits.

b. Outpatient medical treatment expenses for students:

To maintain and develop school health networks, serve physical education activities, guide the prevention of school-related diseases, and provide health care for students at schools; for schools with school health rooms, health staff, and a student enrollment of over 600 or more than 50% of the school's total student population participating in health insurance, the allocation of funds for student health insurance medical treatment expenses is as follows:

- 20% allocated to school health rooms for initial health care and support in implementing certain health education activities for students as stipulated in Circular No. 03/2000/TTLT-BYT-BGD&ĐT dated March 1, 2000, jointly issued by the Ministry of Education and Training and the Ministry of Health regarding school health work;

- 40% transferred to the medical facilities where the insured person has registered for medical treatment to cover outpatient medical treatment expenses and payments for cases where patients are referred to higher levels and emergency cases outside the designated level;

- The remaining 40% is managed by the Social Insurance Authority to pay for inpatient medical treatment expenses and direct payments to patients as prescribed.

In cases where schools do not have health rooms, dedicated health staff, and the student participation rate is less than 50%, the district Social Insurance Authority will coordinate with the schools to sign contracts with convenient healthcare facilities to use 20% of the funds for initial health care for students and trainees.

2.2. Provincial and centrally-administered city Social Insurance Authorities shall cooperate with relevant agencies to audit and propose the Vietnam Social Insurance to consider supplementing funds from the surplus of the voluntary medical treatment fund for the following cases:

+ Funds transferred to medical facilities for outpatient medical treatment and payments for cases where patients are referred to higher levels and emergency cases outside the designated level are insufficient.

+ Medical treatment expenses of health insurance patients exceeding the payment ceiling due to objective reasons affecting the normal operation of medical facilities.

If the voluntary medical treatment fund does not have a surplus, it will be regulated according to Decision No. 02/2003/QĐ-TTg dated January 2, 2003, issued by the Prime Minister on financial management regulations for the Vietnam Social Insurance.

2.3. At the end of the fiscal year, if there is a surplus in the centralized voluntary medical treatment expense fund, it will be allocated and used as follows:

- 80% transferred to the voluntary medical treatment reserve fund at the Vietnam Social Insurance.

- 20% for evaluating and rewarding groups and individuals who have made significant contributions to the implementation of voluntary health insurance (both within and outside the social insurance sector). The Vietnam Social Insurance will guide and implement the allocation of this fund within the system.

3. The voluntary medical treatment fund shall be recorded, statistically reported, and accounted for according to the current regulations of the Ministry of Finance.

VII. IMPLEMENTATION ORGANIZATION

This circular takes effect 15 days after its publication in the Official Gazette. Previous provisions contrary to this circular are hereby abolished. Those who participated in voluntary health insurance before the issuance of this circular, whose health insurance cards remain valid, may continue to use them and enjoy the benefits stipulated at the time of issuance until the expiration date indicated on the card.

Any difficulties encountered during the implementation should be reported to the relevant ministries for study and resolution./.