Chương VI Nghị định 146/2018/NĐ-CP: Thanh toán chi phí khám bệnh, chữa bệnh giữa cơ quan bảo hiểm xã hội và cơ sở khám bệnh, chữa bệnh

Chapter VI

ARRANGEMENT FOR PAYMENT OF MEDICAL COSTS BETWEEN SOCIAL INSURANCE AGENCIES AND HEALTHCARE ESTABLISHMENTS

Article 24. Service price-based payment

1. Payment made based on a service price refers to the method of payment of medical costs on the basis of the price of the medical examination and treatment service which is decided by a competent regulatory authority and costs of medicines, chemicals, medical supplies, blood, blood products which have not yet been included in the service price when being used for treatment of patients at a healthcare establishment.

2. The method for making payments based on prices of medical services shall be applied to the payment of health insurance-covered medical costs, except those costs of medical services which have been settled according to another payment method.

3. Payment principles:

a) The prices of health insurance-covered medical services shall be applied uniformly to same-rank hospitals nationwide;

b) If costs of medicines, chemicals and medical supplies have not been yet included in the prices of medical services, they shall be settled at the purchase prices under legislation on bidding;

c) Costs of blood and blood products shall be settled following instructions given by the Minister of Health.

4. Total annual payment of health insurance-covered medical costs to healthcare establishments shall be calculated according to the following formula:

T= [T_n-1 x k] _{medicines, chemicals} + [T_n-1 x k] _{medical supplies} + [T_n-1] _{blood, blood products} +[T_n-1] _{medical services} + C_n

Where:

a) T means total payment of health insurance-covered medical costs at a healthcare establishment equal to an addition of total inpatient medical cost and total payment of outpatient medical costs;

b) T_n-1 means the health insurance-covered medical cost incurred in the preceding year at a healthcare establishment of which settlement is audited by the social insurance agency;

c) k means the indexing factor indicating any adjustment made owing to any change in the price of medicines, chemicals and medical supplies at a healthcare establishment, relevant to specific elements of medicines, chemicals and medical supplies which have not been included in service prices, exclusive of costs included in C_n.

d) C_n means the cost increasing or decreasing within a year at a healthcare establishment for the following reasons: applying new technologies; providing an additional amount of medicines, chemicals and medical supplies; applying new prices of health insurance-covered medical services; applying new prices of blood and blood products; adjusting hospital ranks; adjusting persons eligible to be awarded health insurance cards; changing the scope of operations of the healthcare establishment under the competent authority’s decisions (if any); changing illness models; changing the number of a patient’s medical visits. This cost shall be integrated into the actual cost used as a basis for calculation of total payment of health insurance-covered medical costs to that healthcare establishment.

5. The health insurance fund shall pay medical costs based on the annual financial report of a healthcare establishment which have been evaluated but do not exceed total payment of health insurance-covered medical costs determined according to clause 4 of this Article.

6. On an annual basis, depending on the price indices of specific elements of medicines, chemicals and medical supplies, declared by the General Statistics Office, the Ministry of Health shall inform the k coefficient after reaching an agreement with the Ministry of Finance.

Article 25. Capitation payment

1. The capitation payment method shall be applied to healthcare establishments providing health insurance-covered outpatient medical services.

2. The capitation payment method shall be applied to costs in the list of health insurance-covered costs with entitlement rates with respect to health insurance card holders registering primary care services and those registering primary care services at another healthcare establishment who seek care at the healthcare establishment making capitation payments.

3. The capitation payment method shall not applied to diseases, groups of diseases, medical services or medical costs which are not in the list of those permitted for capitation payments, regulated by the Minister of Health.

4. The capitation payment fund’s allocations given to healthcare establishments providing health insurance-covered medical services must be within the provincial-level or national capitation payment fund limit.

5. Handling of the difference in the capitation payment fund’s allocations given to healthcare establishments

a) In case where the capitation payment fund has the residual value (i.e. the positive difference in which the capitation payment fund’s allocations are greater than medical costs), the healthcare establishment shall be required to post such residual value into its revenues and use it as a basis for determination of the next year’s capitation payment fund. In case where a healthcare establishment is authorized to sign a contract for provision of primary care services, even including commune-level health stations, it shall be responsible for transferring a part of the residual value to a commune-level health station;

b) In case of the capitation payment fund’s overspending within a financial year (i.e. the negative difference in which the capitation payment fund's allocations are less than medical costs), the healthcare establishment shall balance its revenue of their own accord in compliance with regulations in force.

6. In case where total cost falling within the national capitation payment fund’s annual limit on allocations is greater than total allocations already given by that fund, the Vietnam Social Security shall send a general report to the Council for Management of Vietnam Social Security for its approval and preparation of another report for submission to the Ministry of Finance and the Ministry of Health. The Ministry of Health shall preside over and cooperate with the Ministry of Finance in reviewing the submitted report and preparing the consolidated report for submission to the Prime Minister to seek decisions.

7. The Minister of Health shall regulate the scope and schedule of implementation, techniques for determination of the fund and capitation payment as prescribed in this Article.

Article 26. Payment of patient transportation costs

1. Patient transportation costs must be paid if a health insurance policyholder defined as one of those referred to in clause 3, 4, 7, 8, 9 and 11 of Article 3 hereof seeks emergency care or wishes to refer to shift the level of medical practices from a district-level healthcare establishment to the higher-level one, including:

a) From the district level to the provincial level;

b) From the district level to the central level.

2. Rate of payment of transportation costs:

a) In case of use of the means of transport owned by a referring healthcare establishment, the health insurance fund shall pay two-way transportation costs to that healthcare establishment at the rate equal to 0.2 petrol litre/kilometer based on the actual distance between two healthcare establishments and the petrol price quoted at the time of referral. If there is more than one patient transported on the same vehicle, the rate of payment shall be the same as that for transportation of a single patient. The receiving healthcare establishment shall sign on the transport order issued by the referring healthcare establishment; in case of such referral occurring out of administrative hours, the receiving physician's signature shall be required;

b) In case of use of the means of transport which is not owned by a referring healthcare establishment, the health insurance fund shall pay one-way (departing) transportation costs to that healthcare establishment at the rate equal to 0.2 petrol litre/kilometer based on the actual distance between two healthcare establishments and the petrol price quoted at the time of referral. The referring healthcare establishment shall be responsible for paying these costs directly to a patient before his/her referral, and then making payment arrangements with a social insurance agency.

Article 27. Payment of medical costs in certain cases

1. With respect to payment of medical costs to children under 6 years of age, if they have not been awarded health insurance cards, the healthcare establishment shall prepare the list of under-six-years-old children and health insurance-covered medical costs belonging in the list of costs covered by health insurance benefits with respective benefit entitlement rates for submission to the social insurance agency in accordance with regulations in force.

The receiving social insurance agency shall, based on the list of children who are sent from another healthcare establishment and have been provided with medical care services, assume responsibility for checking and verifying the issuance of health insurance cards to these children; making payments for medical costs. If they have not been awarded health insurance cards yet, these cards must be issued in accordance with regulations in force.

2. With respect to payment of medical costs to a person donating his/her organs, if he/she is required to receive medical treatment after donation but he/she has not been awarded the health insurance card yet, the healthcare establishment receiving his/her organ shall be responsible for preparing the list of donators and medical costs in the list of costs covered by health insurance benefits together with respective rates of benefit entitlement after donation for submission to the health insurance agency for completion of payments in accordance with regulations in force.

The health insurance agency shall, based on the list of organ donators who have receive medical examination and treatment services after donation and costs sent by the healthcare establishment, make payments and issue health insurance cards.

3. With respect to payment of medical costs of a patient participating 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 in accordance with point dd of clause 1 of Article 14 hereof:

a) If a patient makes co-payment for each visit or multiple visits for medical care at the same healthcare establishment which is greater than the base pay amount received during 6 months, that healthcare establishment shall not be allowed to collect the patient’s co-payment which is greater than the base pay amount that he/she has received during 6 months. The healthcare establishment shall be responsible for providing an invoice for the co-payment amount equal to the base pay amount during 6 months so that the patient can use it as a basis for requesting the health insurance agency to give its certification of exemption from making any co-payment in that year;

b) In case where the patient's accrued amount of co-payments in a financial year at different healthcare establishments or at the same healthcare establishment is greater than 6 months’ base pay amount, that patient may present evidencing documents to the social insurance agency issuing his/her health insurance card to pay the amount of co-payment greater than 6 months’ total base pay amount and receive the certification of exemption from co-payment in that year;

c) In case where the patient's co-payment amount is greater than the 6 months’ total base pay amount as from January 1, the health insurance fund shall cover 100% of costs incurred from healthcare services falling within the scope of a patient’s interests from the anniversary date of 5 consecutive years of health insurance participation to the end of December 31 in that year.

4. With respect to a hospital referral, if medical staff is required to accompany the patient, and medicines or medical supplies used to meet medical demands during the process of patient transportation are needed, costs incurred from use of these medicines or medical supplies shall be taken into account as medical care costs of the referring healthcare establishment.

5. In case where a patient retrieves a stable health conditions after the inpatient care stage, but continues to use medicines after hospital discharge according to the healthcare establishment's medical indication, subject to regulations of the Minister of Health, the health insurance fund shall pay costs of medicines falling in the list of health insurance-covered medicines with respective coverage rates determined according to the prescribed insurance benefits. The healthcare establishment shall enter costs of medicines into costs of medical care services of a patient before hospital discharge.

6. In case where a healthcare establishment does not perform any subclinical test, imaging diagnosis, functional assessment and has to refer a patient or send a pathology specimen to another healthcare establishment providing health insurance-covered medical services or any healthcare establishment accredited by a competent authority to render these services, the health insurance fund shall pay costs incurred from performing medical services in the list of health insurance-covered medical services with respective coverage rates in accordance with regulations adopted by the healthcare establishment referring the patient and sending the pathology specimen. The healthcare establishment referring the patient and sending the pathology specimen shall be responsible for paying costs incurred by the receiving healthcare establishment or the service provider, and then entering these costs into the patient’s medical costs as a basis for making payment arrangements with the social insurance agency.

The Minister of Health shall regulate principles and the list of subclinical test, imaging diagnosis and functional assessment services allowed to be sent to a healthcare establishment or a service provider.

7. Payment of medical costs for medical technology services performed by staff members of the transferor healthcare establishment of medical technologies according to programs for giving directions to lower-level healthcare establishments and schemes for promotion of professional competencies for the transferee healthcare establishment of medical technologies or medical technology transfer contracts under regulations promulgated by the Minister of Health.

a) If a medical technology service is transferred under the approval decision of a competent authority to the healthcare establishment receiving the handover of that medical technology service, the health insurance fund shall make payments at the approved service price;

b) If a medical technology service is not approved by a competent authority for transfer to the healthcare establishment receiving the handover thereof, the transferee healthcare establishment shall be responsible for informing a social insurance agency signing the health insurance-covered medical service contract in writing of medical technology services permitted to be provided according to programs, schemes or contracts as a basis for payments, and concurrently submit the list of medical technology services to the competent authority for its approval for provision of these services upon receipt thereof;

c) As for costs incurred from use of medicines, chemicals or medical supplies, the health insurance fund shall pay them at the purchase prices determined by the healthcare establishment providing health insurance-covered medical services in accordance with existing regulations on bidding.

8. With respect to payment of medical costs, if a healthcare establishment uses a new medical technology and method approved by a competent authority and their service price has not been regulated yet, that healthcare establishment must set and apply for the competent authority’s approval of prices of medical technology services as a basis for payment. In this case, the healthcare establishment must inform the social insurance agency in writing of use of a new medical technology or method.

9. If the health insurance card of a health insurance card holder who is receiving inpatient treatment services at a healthcare establishment has expired, his/her medical costs may be covered by the health insurance fund provided that medical services that he/she has received belongs in the list of health insurance-covered medical services with respective coverage rates until the date of his/her hospital discharge, and the interval between the expiration date and the date of receipt of medical services does not exceed 15 days. The healthcare establishment shall be responsible for informing the patient and the social insurance agency signing a health insurance-covered medical service contract with that healthcare establishment so that the patient continues to participate in the health insurance, and the social insurance agency issues or renews the patient’s health insurance card when he/she is receiving medical treatment services at that healthcare establishment.

10. Payment of medical costs with respect to a healthcare establishment providing health insurance-covered medical services on weekly rest days and holidays:

a) When receiving medical services at the healthcare establishment, health insurance card holders shall be entitled to the health insurance fund’s coverage for medical services in the list of health insurance-covered medical services with respective coverage rates;

b) The healthcare establishment shall be responsible for satisfying personnel and professional requirements, publicly disclosing costs that are paid at the patient's expense and are not in the list of health insurance-covered medical costs with respective coverage rates, and informing the patient of this in advance; sending a written notification to the social insurance agency so that they supplement the health insurance-covered medical service contract with terms and conditions of provision of medical services on weekly rest days and holidays as a basis for later payments before the official provision of such medical services.