Chương II Nghị định 105/2014/NĐ-CP: Mức hưởng bảo hiểm y tế và phương thức thanh toán chi phí khám bệnh, chữa bệnh bảo hiểm y tế

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.