Nghị định 105/2014/NĐ-CP hướng dẫn Luật Bảo hiểm y tế

DECREE

PROVIDING DETAILS AND DIRECTIVES ON THE IMPLEMENTATION OF SEVERAL ARTICLES OF THE LAW ON HEALTH INSURANCE

Pursuant to the Law on Government Organization dated December 25, 2001;

Pursuant to the Law on Health Insurance dated November 14, 2008 and the Law on amending and supplementing the Law on Health Insurance dated June 13, 2014;

At the request of the Minister of Health,

The Government hereby promulgates the Decree on providing directives on the implementation of a number of articles of the Law on Health Insurance.

Chapter I

CONTRIBUTING ENTITIES, CONTRIBUTION RATES, SUBSIDY AMOUNTS, AND STATE EXPENDITURES ON THE CONTRIBUTION AND SUBSIDIZATION OF HEALTH INSURANCE PREMIUMS

Article 1. Contributing entities eligible for health insurance contribution

In addition to the entities stipulated in Clause 1, 2, 3, 4 and 5 Article 12 on amending and supplementing the Law on Health Insurance, other entities stipulated in Clause 6 Article 12 on amending and supplementing the Law on Health Insurance include:

1. Rubber plantation workers who are entitled to the monthly allowance under the Decision No. 206/CP dated May 30, 1979 adopted by the Governmental Council (now called the Government) on the government incentives for post-Liberation workers who used to work in a hazardous and arduous working condition but now quit their jobs due to old age as stipulated in Clause 2 Article 12 on amending and supplementing the Law on Health Insurance.

2. Those who belong to family households, work in agriculture, forestry, aquaculture and salt farming sectors, and only afford an average standard of living as stipulated in Clause 4 Article 12 on amending and supplementing the Law on Health Insurance.

Article 2. Contribution rates

1. As from January 1, 2015, the rate of monthly health insurance contribution for eligible contributing entities shall be specified as follows:

a) Equal 4.5% of monthly pay per an employee who belongs to the entities stipulated at Point a Clause 1 Article 12 on amending and supplementing the Law on Health Insurance.

In respect of female employees entitled to paid maternity leaves from work as stipulated by the Social Security Law, the monthly contribution rate shall equal 4.5% of monthly pay that they receive before taking their maternity leave;

In respect of employees entitled to paid sick leaves from work for the period of more than 14 days off as stipulated by the Social Security Law, their pay shall be exempt from health insurance contribution but still eligible to enjoy the entitlement to their health insurance benefits;

In respect of employees held in detention, custody or temporarily suspended from their work before being investigated or judged guilty or not guilty of their offences, the monthly contribution rate shall equal the proportion of 4.5% to 50% of monthly pay that these employees receive in accordance with laws. Where employees are judged not guilty of any offence by competent agencies, they are required to make retrospective payment for their health insurance contribution arrears in proportion to the amount of retrospective salary payments that they are entitled to receive before being away from work;

Employees sent abroad for study or business trips shall be exempt from health insurance contribution; from such period to the time when they return after receiving the decision made by their employers, their health insurance contribution is kept uninterrupted.

Employees shall be exempt from health insurance contribution for the period when they work abroad; within a period of 60 days since their entry into their home country, if they start participating in the health insurance, a full length of the time when they work overseas and an entire span ranging from the time when they return to the time when they commence their health insurance contribution shall be considered as a continuous term of health insurance contribution.

For the period when employees are processing procedures for their entitlement to unemployment benefits in accordance with regulations laid down in the Law on Employment, if they have not participated health insurance as other groups of the insured have done, such period shall be recorded as their term of health insurance contribution.

b) Equal 4.5% of base pay per an employee who belongs to the entities stipulated at Point b Clause 1 Article 12 on amending and supplementing the Health Insurance Law.

c) Equal 4.5% of retirement pension or incapacity benefit per an employee who belongs to the entities stipulated at Point a Clause 2 Article 12 on amending and supplementing the Law on Health Insurance.

d) Equal 4.5% of base pay per an employee who belongs to the entities stipulated at Point b, c Clause 2 Article 12 on amending and supplementing the Law on Health Insurance, and the entities stipulated at Clause 1 Article 1 hereof.

dd) Equal 4.5% of unemployment benefit per an employee who belongs to the entities stipulated at Point d Clause 2 Article 12 on amending and supplementing the Law on Health Insurance.

e) Equal 4.5% of base pay per an employee who belongs to the entities stipulated at Point b, c, d, dd, e, g, h, i, k, l, m and n Clause 3, and Clause 4, 5 Article 12 on amending and supplementing the Law on Health Insurance, and the entities stipulated at Clause 2 Article 1 hereof.

Where infants have reached the age of 72 months but still wait for the school term, the health insurance card shall be valid till September 30 of such year without having to pay contributions to their health insurance policies.

g) In respect of the health insurance contribution rate for all members of family households stipulated in Clause 5 Article 12 on amending and supplementing the Health Insurance Law, the contribution rate for the first contributor shall equal 4.5% of his/her base pay while the second, third and fourth contributor shall pay 70%, 60% and 50% of the first contributor’s contribution rate respectively; the fifth contributor and so forth shall pay contributions to the health insurance policy at the contribution rate equal to 40% of the first contributor’s contribution rate.

In respect of family households whose health insurance contributions are subsidized by the state budget, deductions from their contribution rate is not applicable in accordance with regulations laid down at Point g Clause 1 of this Article.

2. Based on the practical condition, the Ministry of Health shall take charge of cooperating the Ministry of Finance and relevant entities to send a written request to the Government to adjust the rate of health insurance contributions in order to keep the health insurance fund balanced.

Article 3. State expenditures on the subsidization of health insurance contributions of several contributing entities

1. The subsidization rate for health insurance contributions of members of families living in near poverty in accordance with regulations laid down at Point a Clause 4 Article 12 on amending and supplementing the Health Insurance Law shall conform to the followings:

a) Subsidize 100% of health insurance contributions to which nearly-poor members of families are entitled after newly escaping from poverty with the 5-year subsidization term. Where nearly-poor members of families have escaped from poverty before January 1, 2015 but the span ranging from the poverty escape to January 1, 2015 is less than 05 years, the residual subsidization time shall be at least 01 year;

b) Subsidize 100% of health insurance contributions to which nearly-poor families residing at poor districts are entitled in accordance with regulations laid down in the Government’s Resolution No. 30a/2008/NQ-CP dated December 27, 2008 on incentive programs for quick and sustainable reduction in poverty at 61 poor districts and districts with high poverty rate that are eligible for infrastructural investment mechanism and policy in accordance with the Government’s Resolution No. 30a/2008/NQ-CP dated December 27, 2008;

c) Subsidize at least 70% of health insurance contributions per each of the rest of nearly-poor families.

2. Subsidize at least 30% of health insurance contributions per each learner or student in accordance with regulations laid down at Point b Clause 4 Article 12 on amending and supplementing the Health Insurance Law.

3. Subsidize at least 30% of health insurance contributions per each member of families working in agriculture, forestry, aquaculture and salt farming sectors and just affording an average standard of living under the Prime Minister’s Decision No. 32/2014/QD-TTg dated May 27, 2014 as prescribed in Clause 2 Article 1 hereof.

4. The People’s Committee of centrally-affiliated cities and provinces (hereinafter referred to as provincial People’s Committees) shall refer to the affordability of local government budget and other financial sources, inclusive of 20% of total residual expenditures on health check and disease cure within a specified year in accordance with regulations set out in Clause 3 Article 35 on amending and supplementing the Health Insurance Law (if any) in order to define and request the provincial People’s Councils to define the higher subsidization rate of health insurance contributions to which the entities stipulated at Point c Clause 1, 2, 3 of this Article are entitled.

Chapter II

HEALTH INSURANCE COVERAGE RATE AND METHOD OF PAYMENT FOR THE POLICY-HOLDER’S MEDICAL EXPENSES

Article 4. Health insurance coverage rate for the cases stipulated in Clause 1, 7 Article 12 on amending and supplementing the Law on Health Insurance

1. Where the holder of health insurance policy takes the medical care as regulated in Article 26, 27 and 28 of the Health Insurance Law, and Clause 4, 5 Article 22 on amending and supplementing the Health Insurance Law, the health insurance fund shall be liable for covering medical expenses within the scope of insurance coverage defined at the rate as follows:

a) 100% of medical expenses per each policy-holder who belongs to the entities stipulated at Point d, e, g, h, i Clause 3 Article 12 on amending and supplementing the Law on Health Insurance;

b) 100% of medical expenses, and no imposition of restraint on the rate of payments on several medicines, chemicals, medical supplies and technical services in accordance with regulations enforced by the Minister of Health on revolutionary activists, who took part in revolutionary activities before January 1, 1045, from January 1, 1945 to the August revolution date of 1945; Vietnamese heroic mothers; wounded or injured warriors or those eligible for the entitlement to government benefits the same as wounded warriors, Class-B wounded warriors, ill soldiers who have a 81% or greater disability rating on their labor capacity losses; wounded or injured warriors or those eligible for the entitlement to government benefits the same as wounded warriors, Class-B wounded warriors, ill soldiers in treatment for their injuries or relapse; children under 6 years of age;

c) 100% of medical expenses, when medical care is taken at communal health centers;

d) 100% of medical expenses, when the cost incurred by each medical care remains lower than 15% of base pay;

dd) 100% of medical expenses, when insured patients have experienced 5 years of their uninterrupted participation in health insurance that lasts for a period from the time when such patients start participating in the health insurance to the time when they receive such medical care, and make the co-payment greater than their 6-month base pay for an accrued amount of medical expenses within an insurance year beginning on the time when their participation in health insurance has fully reached 5 continuous years, except for the case in which insured patients are covered for their medical expenses incurred from healthcare providers outside of the insurance network.

a) 95% of medical expenses per each policy-holder who belongs to the entities stipulated at Point a Clause 2, Point k Clause 3, and Point a Clause 4 Article 12 on amending and supplementing the Law on Health Insurance;

g) 80% of medical expenses per other policy holders.

2. Where the holder of health insurance policy receives medical care at healthcare centers located in the close proximity of other centrally-affiliated cities and provinces (hereinafter referred to as cities or provinces), the health insurance fund shall cover medical expenses incurred within the limit on benefit and coverage rate stipulated in Clause 1 of this Article, which shall apply to the following cases:

a) Medical care provided by commune’s health stations, general clinics and district’s hospitals;

b) Transfer of insured patients to professional and technical healthcare network of a commune, district or province.

Presidents of the provincial People’s Committees shall direct the Department of Health to take charge of cooperating with Social Security Offices of cities or provinces in managing healthcare services provided for policy-holders at such neighboring areas in accordance with the joint instructions from the Ministry of Health and the Ministry of Finance on the medical care under health insurance policies at the neighboring areas.

3. In respect of on-demand medical care, the health insurance fund shall make a payment within the limit on its benefit and coverage rate in accordance with the regulations laid down in:

a) Clause 1 Article 4 hereof that applies to policy-holders entitled to healthcare services enshrined in Article 26, 27 and 28 of the Law on Health insurance, and amended or supplemented Clause 4, 5 and 6 Article 22 of the Law on Health insurance in which case the insured patient shall be liable for medical expenses incurred in excess of the statutory limit on benefit and coverage rate;

b) Amended and supplemented Clause 3 Article 22 of the Law on Health Insurance applied to the insured patients who receive medical care outside of the insurance network in which case such patients shall be liable for medical expenses incurred in excess of the statutory limit on benefit and coverage rate.

Article 5. Use of method of payment for medical expenses according to amended and supplemented Article 30 of the Law on Health insurance

1. Capitation payment method shall be applicable to the primary healthcare providers.

2. Fee-for-service and per-visit payment methods shall be applicable to:

a) Healthcare providers that do not use the capitation payment method;

b) Payments for non-capitated medical services provided by the healthcare provider who uses the capitation payment method;

c) Payments for medical services to insured patients transferred to the healthcare provider who uses the capitation payment method.

3. The Ministry of Health shall direct and cooperate with the Ministry of Finance in providing detailed instructions on and preparing specific plans for healthcare providers’ proper use of payment methods as stipulated in Clause 1 and 2 of this Article.

Chapter III

MANAGEMENT AND UTILIZATION OF HEALTH INSURANCE FUND

Article 6. Distribution and utilization of health insurance fund

Total revenues from the contribution of health insurance premiums generated in a centrally-affiliated city and province at the contribution rate enshrined in Article 2 hereof shall be distributed and utilized as follows:

1. 90% of health insurance contributions to healthcare services (hereinafter referred to as healthcare fund) that serves the following purposes:

a) Make payment for expenses incurred within the amount of benefits to which the policy-holder is entitled under the regulations laid down in amended and supplemented Article 22 of the Health Insurance Law and Article 4 hereof.

b) Reserve a portion of health insurance contributions at educational institutions that belong to the national education system and conform to the requirements set out by the Ministry of Health with the intent of purchasing medicines, medical consumables, general medical equipment and devices in order to serve the purpose of making arrangements for the practice of primary healthcare services provided for children, learners and students.

The reserved amount of health insurance contributions for educational institutions that belong to the national education system shall make up 7% of total revenues in proportion to the contribution of total number of insured learners or students studying at educational institutions (including learners and students participating in the health insurance in other groups of contributing entities), and the equivalent rate of health insurance contributions for which each contributing entity shall be liable as stipulated in Article 2 hereof; 5% of total revenues in proportion to total children under 6 years of age studying at kindergartens.

In the first month of an academic year or course, social insurance offices shall be responsible to transmit the aforementioned sum to educational institutions and account for such expenditures into a general medical expense statement within their authority. Educational institutions being expenditure receivers shall be responsible for using, accounting for and making financial statements on expenditures, which shall be then reported to superior administrators in accordance with legal regulations.

c) Retain an amount of health insurance contributions in order for agencies, organizations or enterprises that operate their own healthcare facilities to provide primary healthcare services for their staff (except for those that enter into a contract for primary healthcare services covered by health insurance with social insurance organizations). The rate of reserved health insurance contributions shall equal 1% of total sum of health insurance contributions that agencies, organizations or enterprises have paid to social insurance organizations.

The Ministry of Health and the Ministry of Finance shall provide detailed instructions on the implementation of Point b, c Clause 1 of this Article on requirements, scale, spending items, management and financial statements concerning this source of expenditures.

2. 10% of health insurance contributions set aside for the reserve fund and pay expenses incurred by the management of health insurance fund in which at least 5% of health insurance contributions is used for the reserve fund and regulated as follows:

a) Total amount of annual administrative expenditures for the health insurance fund the shall be decided by the General Director of Vietnam Social Security in proportion to total administrative expenditures allocated to Vietnam Social Security after being approved by the Prime Minister;

b) Reserve fund is created by the retained amount of deductions from payments for administrative expenses of the health insurance fund.

3. The management and utilization of revenues gained from the contribution of health insurance premiums shall be regulated as follows:

a) Social Insurance Offices at all administrative levels, affiliated to Vietnam Social Security, shall directly collect health insurance contributions that various contributing entities have paid, and transmit the collected amount to Vietnam Social Security according to the instructions provided by Vietnam Social Security;

b) Vietnam Social Security shall be responsible for timely transferring a full amount of expenditures to meet the demand of Social Insurance Offices at provincial and municipal levels for advances or payments on medical expenses covered by health insurance in accordance with legal regulations.

4. Based on the data available on the financial statement approved by the Management Council of Vietnam Social Security, an amount of expenditures that has not been used up at cities or provinces where revenues gained from the contribution of health insurance premiums used for medical services are greater than medical expenses within an insurance year shall be distributed as follows:

a) With regard to the amount of expenditures used to cover medical expenses that have not been used up in 2014, Vietnam Social Security shall be responsible for accounting for the whole remaining amount into the reserve fund;

b) From January 1, 2015 to December 31, 2020, Vietnam Social Security shall be responsible for accounting for 80% of that amount into the reserve fund, simultaneously report 20% of that amount of expenditures to local social insurance organizations to prepare their spending plan in accordance with regulations laid down at amended and supplemented Point a Clause 3 Article 35 of the Law on Health Insurance.

Based on the amount of expenditures that has not been locally used up, the Department of Health shall direct and cooperate with the Department of Finance and Social Security Office of cities or provinces in preparing the use plan for submission to the provincial People’s Committees to obtain their approval and send a report to the provincial People’s Councils. Based on the approval of provincial People’s Committees, Social Security Office of cities or provinces shall allocate expenditures to relevant entities for their spending plan.

Entities that receive such budget shall be responsible for carrying out management and utilization in accordance with applicable laws, work with the Social Security Office of cities of provinces to make the account settlement for the purpose of recording all of payments into the health insurance fund of cities or provinces, which must ensure the conformity with the given purposes, efficiency, public disclosure and transparency.

c) From January 01, 2021, Vietnam Social Security shall be responsible for bringing forward the entire budget that have not been used up into the reserve fund that serves as the regulator for all operations.

Article 7. Management and utilization of the reserve fund

1. The reserve fund managed by Vietnam Social Security shall be entitle to use to provide supplement to the budget for medical expenses covered by Social Insurance Offices of cities or provinces in case the amount of revenue gained from the contribution of health insurance premiums used to make payment for medical expenses in accordance with regulations laid down in Clause 1 Article 6 hereof remains less than the amount of payments for medical expenses within an insurance year. After completing the report on inspection of annual account settlement, Social Insurance Offices of cities or provinces must send such report to Vietnam Social Security for their verification in order to supplement total differential rate of expenditures with the amount derived from the reserve fund.

2. Where the reserve fund is not sufficient to provide supplementary sums for medical expenditures that arise in cities or provinces under regulations set out in Clause 1 of this Article, Vietnam Social Security is obliged to consult with its Management Council to find solutions before sending a report to the Ministry of Health and the Ministry of Finance.

The Ministry of Health shall direct and cooperate with the Ministry of Finance in sending a report to the Government to seek any possible solution in order to ensure the adequate and timely-distributed amount of budget for medical expenses covered under health insurance policies as prescribed by laws.

Article 8. Expenses for the administration of health insurance fund

1. Recurrent expenditures that conform to legal regulations shall include:

a) Spending on particular works such as:

- Communicative and cooperative activities that work towards the growth of health insurance;

- Activities concerning the task of collecting revenues and paying expenses for the health insurance fund;

- Cooperative activities relating to the inspection, examination and supervision of health insurance operations.

b) Operating expenses for health insurance mechanism that help to manage health insurance funds at all administrative levels.

2. Non-recurring expenses shall include:

a) Spending on the development and modernization of information technology;

b) Spending on scientific researches, training, education and international cooperation in the health insurance sector.

3. Other expenses in accordance with laws.

The Ministry of Finance shall provide detailed instructions on spending accounts and rates enshrined in this Article.

Article 9. Investment activities of health insurance fund

1. Temporarily idle cash available at the health insurance fund shall be used to carry out the investment tasks which conform to the investment types regulated in the Law on Social Insurance.

2. The Management Council of Vietnam Social Security shall decide and be held accountable to the Government for the investment type and structure of the health insurance fund upon the request of Vietnam Social Security.

3. All of annual net income yielded from the investment activities of the health insurance fund shall be set aside to complement the reserve fund that serves as the regulator for entire operations.

Article 10. Financial settlement and plan preparation

1. Vietnam Social Security must complete the report on financial settlement by October 01 of the subsequent year in accordance with the regulations laid down in amended and supplemented Article 32 of the Law on Social Insurance.

2. Every year, Vietnam Social Security shall prepare the financial plan for revenues and expenditures, administrative expenses and investments derived from temporarily idle cash of the health insurance fund, which shall be then submitted to the Management Council of Vietnam Social Security to obtain the approval and make a report to the Ministry of Finance and the Ministry of Health.

The Ministry of Finance shall take charge of cooperating with the Ministry of Health in submitting a summary report to the Prime Minister for the decision on annual financial plan.

3. Within a period of 15 days from the receipt of the Prime Minister’s decision on the budget plan, Vietnam Social Security shall be responsible for allocating the estimated norms of revenues and expenditures to relevant regulatory bodies.

Chapter IV

IMPLEMENTARY PROVISIONS

Article 11. Transitional provisions

1. Where persons participating in the health insurance keep health insurance cards that are still valid after the date on which the Law on amending and supplementing the Health Insurance Law takes effect, the limit on insurance benefits and coverage rates shall comply with the regulations laid down in the Law on amending and supplementing the Health Insurance Law and in Article 4 hereof.

2. Where the holders of health insurance cards take the medical care provided by a healthcare provider but their health insurance cards have expired, their medical expenses incurred until they are discharged from the hospital or finish their outpatient treatment shall be covered within the limit on insurance benefits and coverage rates.

3. Where persons participating in the health insurance are hospitalized before January 01, 2015 but have been discharged from the hospital since January 01, 2015, their medical expenses shall be covered within the limit on insurance benefits and coverage rates in accordance with the regulations set out in the Law on amending and supplementing the Health Insurance Law and in Article 4 hereof.

4. In respect of the entities stipulated in amended and supplemented Point a Clause 3 Article 12 of the Health Insurance Law, who are retired, discharged from military service, change or quit their jobs, the length of time when they study or work in the people's army, public security and cipher organizations shall be counted in the insurance time span.

5. Learners or students who pay their health insurance contributions for the entire academic year 2014 – 2015 shall not be obliged to retrospectively pay the differential amount of health insurance contributions as stipulated at Point g Clause 1 Article 2 hereof.

6. Educational institutions affiliated to the national education system that have already received a portion of medical funds to provide the primary healthcare for their learners or students before January 01, 2015 must comply with instructions of the Ministry of Finance till the end of the academic year 2014 – 2015.

Article 12. Effect

This Decree shall come into force from January 01, 2015.

The Government’s Decree No. 62/2009/ND-CP dated July 27, 2009 on specifying and guiding the implementation of a number of articles of the Law on Health Insurance shall become defunct from the date on which this Decree takes effect.

Article 13. Responsibility for providing guidance on the implementation of this Decree

1. The Ministry of Health shall preside over their coordination with the Ministry of Finance to provide guidance on the implementation of binding provisions set out in this Decree, the individual participation in the family household’s health insurance policies, and study and make a proposal for solutions to involving all of the population in the health insurance.

2. The Ministry of Finance shall be responsible for properly distributing the central budget to assist local insurance administrators that do not have ability to carry out the budget self-control for the purpose of implementing the health insurance policy as stipulated in this Decree; providing guidance on transferring expenditures derived from the administrative expenditures of the health insurance fund to the People’s Committees of communes in order to compile a list of health insurance policy holders in the given area; providing instructions on implementing binding provisions laid down in this Decree.

3. The Ministry of National Defense and the Ministry of Public Security shall preside over the coordination with the Ministry of Health and the Ministry of Finance to provide guidance on the health insurance policies for the entities stipulated in amended and supplemented Point a, Point 1, Point n Clause 3 and Point b Clause 4 Article 12 enshrined in the Law on Social Insurance.

4. Vietnam Social Security shall be responsible for determining the amount of co-payments accrued every month which serves as the basis for the determination of insurance benefit amounts to which policy holders participating in the health insurance for 05 continuous year are entitled.

5. The Ministry of Labor, War Invalids and Social Affairs shall consider and set criteria for determining family households that work in agriculture, forestry and salt farming sectors, and only afford an average standard of living, which shall be then submitted to the Prime Minister for enforcement.

Provide instructions on compiling the list of family members who work in agriculture, forestry, aquaculture and salt farming sectors, and only afford the average standard of living.

6. Other relevant ministries and agencies within their functions, tasks and powers shall be responsible for providing guidance on the implementation of this Decree.

Article 14. Responsibility for implementation

Ministers, Heads of ministerial-level agencies, Heads of Governmental agencies, the Presidents of People’s Committees of central-affiliated cities and provinces shall assume their responsibility for implementing this Decree./.