Chương IV Nghị định 146/2018/NĐ-CP: Mức hưởng, thủ tục khám bệnh, chữa bệnh bảo hiểm y tế

Chapter IV

BENEFIT ENTITLEMENT RATES, PROCEDURES FOR INSURANCE COVERED HEALTHCARE SERVICES

Article 14. Rates of entitlement to health insurance coverage with respect to cases prescribed in clause 1 and clause 7 of Article 22 in Law on Health Insurance

1. When receiving medical examination and treatment services in accordance with Article 26, 27 and 28 in the Law on Health Insurance; clause 4 and 5 of Article 22 in the Law on Health Insurance, health insurance policyholders shall be entitled to the health insurance fund’s coverage of permissible medical costs at the following rates:

a) 100% of medical costs paid by the policyholders prescribed in clause 3, 4, 8, 9, 11 and 17 of Article 3 herein;

b) 100% of medical costs, and any restrictions on the rate of payment of medical costs such as medicines, chemicals, medical supplies and medical technology services as regulations of the Minister of Health shall not be applied to:

- Revolutionaries performing their activities before January 1, 1945;

- Revolutionaries performing their activities from January 1, 1945 to the date of the uprising event taking place in August, 1945;

- Vietnamese heroic mothers;

- War invalids, beneficiaries of the same compensation policies as war invalids, class-B war invalids and sick soldiers whose labor capacity is reduced by at least 81%;

- War invalids, beneficiaries of compensation policies as war invalids, class-B war invalids and sick soldiers whose injuries are cured or whose diseases relapse;

- Partisans suffering diseases due to exposure to toxic chemicals whose labor capacity is reduced by at least 81%;

- Children under 6 years of age.

c) 100% of healthcare service costs at the commune level;

d) 100% of medical service costs if the cost of each medical examination or treatment accounts for less than 15% of the base pay rate;

dd) 100% of medical costs if a patient participates in the health insurance for a consecutive period of at least 5 years and has made the co-payment of medical costs in a year which is greater than total base pay amount received during 6 months, except self-referrals to inappropriate-level healthcare establishments;

e) 95% of medical costs paid by the policyholders prescribed in clause 1 of Article 2, clause 12 of Article 3, and clause 1 and 2 of Article 4 herein;

g) 80% of medical costs paid by others;

h) With respect to patients who are diagnosed, given therapeutic indications and referred to commune-level healthcare establishments for their management, monitoring and dispensing of medicines by higher-level healthcare establishments under regulations of the Minister of Health, their medical costs shall be paid by the health insurance fund within their scope of insurance benefit entitlement and contribution rates as prescribed in point a, b, dd, e ad g of clause 1 of this Article.

2. If a person is classified into different groups of policyholders, he/she shall be entitled to the health insurance benefit which is offered to the policyholder entitled to the highest health insurance benefit in accordance with clause 1 of this Article.

3. In case where a health insurance card holder visits an inappropriate-level healthcare establishment at his/her discretion, and then is referred to another healthcare establishment by the receiving healthcare establishment, he/she shall be paid the health insurance fund’s coverage at the coverage rate specified in clause 3 of Article 22 in the Law on Health Insurance, except the following cases: he/she is given emergency treatment services; he/she is given inpatient treatment services while being diagnosed with any other disease of which treatment is out of professional capabilities of the referring healthcare establishment; his/her pathological conditions have changed to the extent that they are out of competencies of the referring healthcare establishment.

4. Health insurance policyholders who register their primary healthcare services at commune-level healthcare establishments in adjacent provinces shall be entitled to 100% coverage of costs of healthcare services in the list of covered healthcare services with respective coverage rates as defined in clause 1 of this Article if they are offered medical services rendered by these commune-level healthcare establishments in adjacent provinces.

5. In case of conversion of the health insurance benefit entitlement rate, the new entitlement rate shall be applied from the effective date of the new health insurance card.

Article 15. Procedures for insurance covered healthcare services

1. When visiting healthcare establishments for medical examination or treatment services, health insurance policyholders must present photo health insurance cards; in case of absence of the photo, they shall be required to present one of their photo identity documents issued by competent bodies or authorities, or certificates endorsed by commune-level police authorities or others endorsed by educational institutions in charge of management of pupils or students; other legitimate personal identification documents.

2. When children under 6 years of age go to healthcare establishments to receive medical examination or treatment services, only health insurance cards shall be needed. If a child is not awarded health insurance cards, a copy of the written evidence of birth or a copy of the birth certificate must be shown; in case where such child needs medical treatment after birth but he/she is not awarded the written evidence of birth, the head of the healthcare establishment, parents or guardian of that child shall be required to sign in the medical record as a basis for payment of health insurance benefits as prescribed in clause 1 of Article 27 hereof and shall bear responsibility for their endorsement.

3. When visiting healthcare establishments to receive medical examination or treatment services, a health insurance policyholder who is expecting a new health insurance card which is reissued or replaces the preexisting one must present the note of appointment for reissuance and replacement of health insurance card issued by the social insurance agency or any entity or individual authorized by the social insurance agency to receive applications for reissuance and replacement of health insurance cards by using the Form No. 4 of the Appendix to this Decree, and any document evidencing personal identity of that policyholder.

4. When a health insurance policyholder who has donated his/her organ visits healthcare establishments to receive medical examination or treatment services, he/she must present documents referred to in clause 1 or clause 3 of this Article. In case where the medical treatment is needed immediately after the organ donation, the head of the healthcare establishment performing organ procurement and the patient or the patient's relative must bear their signature on the medical record as a basis for payment of health insurance benefits in accordance with clause 2 of Article 27 hereof, and shall be responsible for their endorsement.

5. In case of a referral to another healthcare establishment at the different level, a policyholder shall be required to present his/her referral dossier formulated by the referring healthcare establishment and the referral form by using the Form No. 6 of the Appendix to this Decree. In case where the referral form is valid until the end of December 31 while the medical treatment has not yet been completed, use of that referral form till the end of that medical treatment shall be allowed.

In case of a follow-up examination, a health insurance policyholder must show the note of follow-up appointment of the healthcare establishment which is prepared by using the Form No. 5 of the Appendix to this Decree.

6. In case the emergency treatment service is needed, a health insurance policy may choose to be hospitalized at any healthcare establishment and shall be required to present documents referred to in clause 1, clause 2 or clause 3 of this Article before discharge from that healthcare establishment. After the emergency treatment stage, if the insured patient is allowed by the healthcare establishment to implement procedures for referral to another ward or department of that healthcare establishment in order for them to receive further health monitoring and treatment, or to be referred to another healthcare establishment, these referrals shall be defined as appropriate-level referrals.

The healthcare establishment that does not enter into the health insurance-covered healthcare service contract shall be responsible for providing patients allowed for hospital discharge with valid documents and evidences relating to medical costs which they use for directly claiming payments of their health insurance benefits at social insurance agencies under the provisions of Article 28, 29 and 30 hereof.

7. If a health insurance policyholder takes up a temporary residence while going on a business trip, working on the move or taking a full-time training program, he/she shall be entitled to receive primary health care at an appropriate-level healthcare establishment or the healthcare establishment at the level equivalent to the healthcare establishment providing primary care which is inscribed on his/her health insurance card, and shall be required to present documents stipulated in clause 1, clause 2 or clause 3 of this Article and one of the following documents (either in the form of an authentic copy or a duplicate): business travel form, decision to send personnel to participate in a training course, student identity card, temporary residence evidencing document and school transfer approval form.

8. Healthcare establishments and social insurance agencies shall not be allowed to adopt supplemental procedures for health insurance-covered services in addition to those procedures stipulated in this Article. In case where healthcare establishments or social insurance agencies need copies of the health insurance card and other documents relating to medical examination and treatment of patients to serve administrative tasks, they shall be required to make copies at their expense and shall not be allowed to request patients to make copies or pay photocopy costs.