Chương VIII Nghị định 146/2018/NĐ-CP: Quản lý và sử dụng quỹ bảo hiểm y tế

Chapter VIII

USE AND MANAGEMENT OF HEALTH INSURANCE FUND

Article 31. Distribution and use of the health insurance fund

Total health insurance contribution amount prescribed in Article 7 hereof shall be distributed and utilized as follows:

1. 90% of such amount intended for medical services (hereinafter referred to as medical service fund) shall be used for the following purposes:

a) Paying costs in the list of health insurance-covered costs of a health insurance policyholder as prescribed in Article 14, 26, 27 and 30 hereof;

b) Setting aside a part of such amount given to educational institutions or vocational training establishments, entities, organizations or enterprises satisfying prescribed requirements in accordance with clause 1 of Article 34 hereof.

2. 10% of health insurance contributions shall be intended for the provisional fund and payment of costs of management of the health insurance fund and shall be subject to the following provisions:

a) The payment amount of costs of management of the health insurance fund is equal to 5% of total health insurance contribution amount. The annual payment amount of costs of management of the health insurance fund and the payment items shall be regulated by the Prime Minister;

b) The amount set aside for the provisional fund is the remaining amount resulting from the deduction from the health insurance fund for costs of management of the health insurance fund under the provisions of point a of this clause, and shall be equal to 5% of total health insurance contribution amount at minimum.

Article 32. Costs of management of the health insurance fund

1. Costs of management of the health insurance fund shall be comprised of the followings:

a) Payments for performing activities by the organizational machineries of all-level social insurance agencies;

b) Payments for propagating and disseminating regulatory policies and law soft; attracting and managing health insurance policyholders; organizing professional training; reforming administrative procedures; carrying out collection activities; conducting inspection and audit activities and other payments in accordance with laws on health insurance;

c) Payments for application of information technologies and capital investments.

2. Specific payment items prescribed in clause 1 of this Article shall be subject to regulations promulgated by the Prime Minister.

Article 33. Payment amounts for primary medical care services

1. The amounts set aside for payments to an educational institution or vocational training establishment shall include:

a) 5% of health insurance revenues in connection with total number of children under 6 years of age, pupils or students studying at that educational institution shall be calculated according to the following formula:

Amount = 5% x (N_{number of persons} x M_{health insurance} x L_base x Th)

Where:

- N_{number of persons}: Number of children under 6 years of age, pupils or students studying at an educational institution or a vocational training establishment participating in the health insurance.

- M_{health insurance}: Rate of payment of health insurance contribution applied to policyholders who are children under 6 years, pupils or students prescribed in clause 1 of Article 7 hereof.

- L_base: Base pay rate determined on the date of payment of health insurance contribution.

- Th: Number of months of health insurance contribution payment.

On a periodic basis, every 03 months, 06 months or 12 months, the social insurance agency shall be responsible for transferring the amount prescribed in this point to an educational institution or vocational training establishment, and consolidating such amount into the financial report of the fund for health insurance-covered medical services.

b) With respect to 1% of the monthly health insurance contribution for an employee working at an educational institution or a vocational training establishment, the social insurance agency shall be responsible for covering this amount immediately after receipt of the health insurance contribution from the educational institution or the vocational training establishment.

2. The amount retained for an entity, organization or enterprise meeting requirements as prescribed in clause 1 of Article 34 hereof shall be equal to 1% of the monthly health insurance contribution amount that such entity, organization or enterprise pays for their employees. The social insurance agency shall be responsible for paying such cost immediately after receipt of the health insurance contribution paid by this entity, organization or enterprise.

3. The amount retained for persons aboard an offshore fishing vessel:

a) The payment amount equal to 10% of the health insurance revenue in connection with the number of persons aboard such vessel who participates in the health insurance for the purpose of buying medicine cabinets, medicines and medical supplies for medical first aid and primary care services shall be calculated according to the following formula:

Amount = 10% x (N_{number of persons} x M_{health insurance} x L_base x Th)

Where:

- N_{number of persons}: Number of participants in the health insurance program who work aboard a fishing vessel.

- M_{health insurance}: Health insurance contribution rate applied to the first policyholder in a family household in accordance with point e of clause 1 of Article 7 hereof.

- L_base: Base pay rate determined on the date of payment of health insurance contribution.

- Th: Number of months of health insurance contribution payment.

b) President of the provincial People’s Committee shall manage purchase and donation of medicine cabinets, medicines and medical supplies for owners of offshore fishing vessels. The health insurance agency shall transfer the amount prescribed in point a of this clause to the entity or organization authorized by the President of the provincial People’s Committee to purchase medicine cabinets, medicines and medical supplies; enter such amount into the financial report of the fund for health insurance-covered medical services.

4. Based on the actual demands and capability of balancing of the health insurance fund, the Minister of Health shall recommend any proper adjustment in the amount retained for payment of primary care costs to the Government for its approval.

Article 34. Medical cost payment and accounting requirements and contents with respect to primary care services

1. The educational institutions, vocational training establishments, entities, organizations or enterprises prescribed in point b of clause 1 of Article 31 hereof (except those that have signed health insurance-covered medical service contracts as per Article 19 hereof) shall be entitled to the health insurance fund’s allocations for performing primary care services if they satisfy the following requirements:

a) Have at least a person who conforms to medical practicing requirements under laws on medical examination and treatment, and work under the single-employment or multiple-employment regime in the primary care domain;

b) Have medical care wards or private rooms for first aid or primary care activities for policyholders under the management of an educational institution or vocational education establishment, entity, organization or enterprise in case of accidents resulting in injuries, common diseases when studying or working at these educational institutions, vocational training establishments, entities, organizations or enterprises.

2. Payment items:

a) Payments for medicines, medical supplies for first aid or primary care services for children, pupils, students policyholders under the management of these entities, organizations or enterprises in case of accident-related injuries, common diseases when studying or working at the abovementioned entities;

b) Payments for purchase and repair of common medical equipment serving the needs of primary care, filing cabinets used for archival of medical records at these entities;

c) Payments for purchase of stationery accessories used for provision of medical services in the primary care domain.

3. Cost payment and settlement:

a) Pubic educational institutions or vocational education establishments shall record medical costs arising in the primary care domain in costs intended for operation of their medical service operations and carry out the settlement thereof with higher-level supervisory units in accordance with existing regulations;

b) Non-pubic educational institutions or vocational education establishments shall record medical costs arising in the primary care domain in their operational costs and carry out the settlement thereof with higher-level supervisory units (if any);

c) Enterprises and economic organizations shall create a separate accounting book to reflect the receipt of the health insurance fund's allocations, the use of these allocations and shall not be allowed to consolidate costs incurred into the cost settlement report of each enterprise or economic organization;

d) Other entities shall record medical costs arising in the primary care domain in costs incurred by performing their healthcare activities of these entities and carry out the settlement thereof with higher-level supervisory bodies (if any) or same-level financial institutions under existing regulations.

4. Educational institutions, vocational training establishments, organizations or enterprises given allocations for medical services in the primary care domain as prescribed herein shall be responsible for using them for primary care services, shall not be allowed to use them for other purposes. The remaining amount of allocations which are given for use to the end of the year and have not been used up shall be brought forward for use in the following year and may not need to be settled with social insurance agencies.

Article 35. Management and utilization of the provisional fund

1. Funding sources:

a) Amounts retained annually as prescribed in point b of clause 2 of Article 31 hereof and point a of clause 3 of Article 35 in the Law on Health Insurance;

b) Amounts derived from deferrals or evasions of health insurance contribution payment;

c) Returns yielded from the health insurance fund’s investments;

d) Interests accruing due to deferred payment or evasion of health insurance contributions.

2. Purposes of the provisional fund’s allocations:

a) Allocations used as supplementary amounts funding medical services in cities and provinces in case of total health insurance revenue intended for medical services referred to in clause 1 of Article 31 hereof which is less than total expenditure in the year. After evaluation of the cost settlement report, the Social Security of Vietnam shall be responsible for offsetting the difference by using the provisional fund.

b) Allocations used as state budget refunds owing to recurring issuance of health insurance cards.

3. In case where the provisional fund is insufficient to provide supplementary amounts for medical services in cities and provinces under point a of clause 2 of this Article, the Vietnam Social Security shall report to the Council for Social Insurance Management and recommend measures to deal with such situation before submitting a consolidated report to the Ministry of Health and the Ministry of Finance.

The Ministry of Health shall preside over and cooperate with the Ministry of Finance in recommending measures to the Government to ensure adequacy and timely provision of funds for health insurance-covered medical services in accordance with regulations in force.

Article 36. Financial planning and settlement

1. On an annual basis, the Vietnam Social Security shall draw up plans for the health insurance fund's revenues and expenditures; funds for management of the health insurance fund and investments derived from temporarily idle amounts of the health insurance fund. The Ministry of Finance shall preside over and cooperate with the Ministry of Health in submitting the review and general report to the Prime Minister to receive his decision on assignment of the financial plan.

2. On an annual basis, prior to October 1, the Vietnam Social Security shall be responsible for preparing the general and cost settlement report of the health insurance fund in the previous year as prescribed in Article 32 of the Law on Health Insurance.