Chương VI Luật bảo hiểm y tế 2008: Thanh toán chi phí khám bệnh, chữa bệnh bảo hiểm y tế

Chapter VI

PAYMENT OF COSTS OF HEALTH INSURANCE-COVERED MEDICAL CARE

Article 30. Methods of payment of costs of insured medical care

1. Costs of health insurance-covered medical care shall be paid by one of the following methods:

a/ Rate-based payment, which means payment according to medical care cost norms and the premium rate fixed on each health insurance card as registered with a health insurance-covered medical care provider during a certain period;

b/ Service charge-based payment, which means payment on the basis of costs of medicines, chemicals, medical supplies and equipment as well as technical services provided for patients;

c/ Disease-based payment, which means payment according to medical care costs pre-determined for each case based on diagnosis.

2. The Government shall specify the application of methods of payment of health insurance-covered medical care costs defined in Clause 1 of this Article.

Article 31. Payment of costs of health insurance-covered medical care

1. Health insurance institutions shall pay costs of health insurance-covered medical care to medical care providers according to health insurance-covered medical care, contracts

2. Health insurance institutions shall pay medical care costs directly to health insurance card holders who use medical care services in the following cases:

a/ At a health insurance-covered medical care provider which has no health insurance-covered medical care contract;

b/ The medical care is provided not in accordance with Articles 26, 27 and 28 of this Law;

c/ In foreign countries;

d/ Other special cases as specified by the Minister of Health.

3. The Ministry of Health shall assume the prime responsibility for, and coordinate with the Ministry of Finance in, specifying payment procedures and levels for cases defined in Clause 2 of this Article.

4. Health insurance institutions shall pay medical care costs on the basis of hospital charges according to the Government’s regulations.

Article 32. Advancement, payment, settlement of costs of health insurance-covered medical care

1. Health insurance institutions shall quarterly pay in advance to health insurance-covered medical care providers at least 80% of the costs of health insurance-covered medical care of the preceding quarter which have been settled. With regard to a health insurance-covered medical care provider which signs a health insurance-covered medical care contract for the first time, the first advance will at least equal 80% of the medical care cost of one quarter under the signed contract.

2. An health insurance-covered medical care provider and a health insurance institution shall make payment and settlement on a quarterly basis as follows:

a/ In the first month of every quarter, the health insurance-covered medical care provider shall send a report on settlement of costs of health insurance-covered medical care in the previous quarter to the health insurance institution;

b/ Within 30 days after receiving the settlement report from the health insurance-covered medical care provider, the health insurance institution shall consider and notify the latter of the results of settlement. Within 15 days after notifying the settlement results, the health insurance institution shall complete the settlement with the health insurance-covered medical care provider.

3. Within 40 days after receiving a complete dossier of request for payment of medical care costs from an insured under Points a and b, Clause 2, Article 31 of this Law or 60 days, for cases defined at Points c and d. Clause 2, Article 31 of this Law, the health insurance institution shall pay the medical care costs to that insured.