Nghị định 75/2023/NĐ-CP sửa đổi Nghị định 146/2018/NĐ-CP hướng dẫn Luật Bảo hiểm y tế

DECREE

ON AMENDMENTS TO DECREE NO. 146/2018/ND-CP DATED OCTOBER 17, 2018 OF THE GOVERNMENT ON ELABORATION OF THE LAW ON HEALTH INSURANCE

Pursuant to the Law on Government Organization of June 19, 2015; Law on amendments to the Law on Government Organization and the Law on Organization of Local Governments dated November 22, 2019;

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

At the request of the Minister of Health,

The Government promulgates a Decree on amendments to Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government on elaboration of the Law on Health Insurance.

Article 1. Amendments to Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government on elaboration of the Law on Health Insurance

1. Amendments to Article 3:

a) Amendments to clause 8:

“8. Persons eligible to receive monthly social subsidies under laws on the elderly, the disabled and subject of social subsidy programs.”;

b) Amendments to point a clause 9:

“a) Members in poor households, as defined according to the poor household criteria for the period 2022-2025 prescribed in Decree No. 07/2021/ND-CP dated January 27, 2021 of the Government on multidimensional poverty criteria for the period 2021- 2025 (hereinafter referred to as Decree No. 07/2021/ND-CP) and other subsequent amendments or replacements thereto;";

c) Add Clause 20 after Clauses 18 and 19, which have been added by Clause 1, Article 183 of Decree No. 131/2021/ND-CP dated December 30, 2021 of the Government on elaboration of the Ordinance on preferential treatment for people with meritorious services to the revolution as follows:

“20. People in safe zone communes and revolutionary safe zones during the resistance war against the French and Americans and currently residing in safe zone communes during the resistance wars against the French and the Americans, who have been updated with information in the National Population Database, Residence Database that are not policyholders specified in Clauses 1, 2 and 3, Article 12 of the Law on Health Insurance.”.

2. Amendments to Article 4:

a) Amendments to clause 1:

“1. Members in near-poor households, as defined according to the near-poor household criteria for the period 2022-2025 prescribed in Decree No. 07/2021/ND-CP and subsequent amendments or replacements thereto;";

b) Amendments to clause 4:

“4. Members in households working in agriculture, forestry, fishery, and salt production who have the average standard of living, as defined according to the average household criteria for the period 2022-2025 prescribed in Decree No. 07/2021/ND-CP and subsequent amendments or replacements thereto;";

c) Addition of clause 5 after clause 4:

“5. Ethnic minorities who are living in communes of Region II, Region III, and extremely disadvantaged villages in ethnic minority and mountainous areas in the 2016-2020 period, but these communes are no longer on the list of communes in Region II, Region III, and extremely disadvantaged villages in ethnic minority and mountainous areas for the period 2021-2025 according to the Prime Minister's decision.".

3. Amendments to Article 8:

a) Amendments to points a and b clause 1:

“a) Pay 100% of health insurance premiums for members of near-poor households residing in poor districts according to the Prime Minister's decision and other documents of competent authorities;

b) Pay at least 70% of health insurance premiums for the policyholders specified in Clauses 1, 2 and 5, Article 4 of this Decree;";

b) Amendments to clause 3:

“3. People’s Committees of provinces and centrally affiliated cities shall, based on the local government budget's capabilities and other legal funding sources, seek approval from the People’s Councils for the following cases:

a) Pay health insurance premiums for policyholders with a rate higher than the minimum rate specified in Points b and c, Clause 1, Article 8 of this Decree;

b) Pay health insurance premiums for people not the policyholders as specified in Clause 1, Article 8 of this Decree;

c) Eligible policyholders and co-pay rates of medical examination and treatment costs (hereinafter referred to as medical cost) for the health insurance policyholders.”.

4. Amendments to Article 9:

a) Amendments to clause 2:

“2. With respect to the policyholders prescribed in clause 3, 5, 8, 11, 12, 18, 19 and 20 of Article 3 hereof: On a quarterly basis, agencies of labor, war invalids and social affairs shall remit funds derived from state budget spending on implementation of compensation policies for persons rendering meritorious revolutionary services, or funds derived from state budget spending on implementation of social protection policies, into the health insurance fund.  Not later than December 15 of each year, agencies of labor, war invalids and social affairs must complete payments and fund transfers to the health insurance fund during that year.”;

b) Amendments to clause 3:

“3. With respect to the policyholders prescribed in Clauses 1, 4, 6, 7, 9, 10, 13, 14 and 17 Article 3 and Clauses 1, 2 and 5 Article 4 of this Decree:

a) On a quarterly basis, social security agencies shall prepare a consolidated report on the number of health insurance cards which have already been issued and the paid premiums and paid premium support amounts according to the Form No. 1 of the Appendix to this Decree, send it to the financial institution to transfer the funds to the health insurance fund as stipulated in clause 9 of this Article;

b) The time of calculation of the health insurance premiums payable: Policyholders shall be listed annually, and their health insurance premiums shall be calculated as from January 1; with respect to policyholders added to the list, their premiums shall be calculated from the date specified in the Decision on approval of the abovementioned list issued by the competent authority.

c) Health insurance premium payment for policyholders who die, disappear, or leave Vietnam is calculated from the time of payment to the date of termination, as determined by the list of employee reductions and premium reductions issued by the competent authority.

5. Amendments points a and e clause 1 Article 14:

a) Amendments to points a:

“a) 100% of medical costs paid by the policyholders prescribed in Clauses 3, 4, 5, 8, 9, 11, 17 and 20 Article 3 herein;”;

b) Amendments to point e:

“e) 95% of medical costs paid by the policyholders prescribed in Clause 1, Article 2, Clauses 12, 18 and 19, Article 3 and Clauses 1, 2 and 5, Article 4 of this Decree;”.

6. Amendment to clause 1 Article 15:

“1. When visiting healthcare establishments for medical examination or treatment services, health insurance policyholders must present photo health insurance cards or citizen identity 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 or level-2 electronic identification (VneID) according to the provisions of Decree No. 59/2022/ND-CP dated September 5, 2022 of the Government on electronic identification and authentication.”.

7. Amendments to Article 21:

a) Amendments to clause 1:

“1. Rights of healthcare facilities:

a) Implement regulations laid down in Article 42 of the Law on Health Insurance and regulations on medical examination and treatment;

b) Be notified promptly when the health insurance assessment information system detects a significant increase in health insurance-covered medical costs at their healthcare facility, compared to the average medical costs of similar facilities of the same class, level, and specialty, to enable prompt review, verification, and implementation of appropriate corrective measures.”;

b) Amendments to point a clause 2:

“a) Carry out responsibilities laid down in Article 43 of the Law on Health Insurance and regulations on medical examination and treatment;”;

c) Amendments to point b clause 2:

“b) Abide by the laws and regulations on medical examination and treatment, professional guidelines of the Ministry of Health, and relevant procurement and bidding laws to ensure the supply of qualified, effective, and economical drugs, chemicals, medical supplies, and procedures;”;

d) Addition of points dd and e to clause 2:

“dd) Develop a healthcare IT infrastructure system, and upgrade and improve the hospital management software system to conform to legal regulations on data input and output standards, electronic data extraction, digital transformation, and electronic transactions in healthcare;

e) Expeditiously review and promulgate processes and professional guidelines for health examinations and treatments covered by health insurance, as well as measures to prevent the abuse and profiteering of health insurance funds; conduct inspections and audits of health insurance-covered medical cost payments in accordance with the law; proactively detect, review, and verify increased health insurance-covered medical costs at the facility based on the social insurance agency's recommendations and warnings, and make appropriate adjustments.”.

8. Amendment to clause 3 Article 24:

"3. Payment principles:

a) Health insurance-covered medical examination, daily hospital bed, medical procedure, and test costs, within their insurance coverage scope and coverage rate, shall be paid in accordance with the actual quantity used by the policyholder and the prices set by applicable regulations;

c) If a health insurance policyholder uses drugs, chemicals, or medical supplies that are not included in the health insurance-covered medical prices, or drugs, chemicals, and medical supplies used in medical procedures that have not yet been issued health insurance-covered medical prices, but these items are within the scope and rate of insurance coverage, then the cost of those items shall be paid in accordance with the actual quantity used and the prices set by the law on bidding;

c) The costs of blood and blood products are paid according to instructions of Minister of Health.”.

9. Amendments to Article 36:

“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 take charge 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. Prepare, assign, and announce the estimated budget for health insurance-covered medical costs:

a) Vietnam Social Security prepares an estimated budget of health insurance-covered medical costs next year (including estimated budget of the Social Security of the Ministry of National Defense and the Social Security of the People's Public Security) and sends it to the Ministry of Finance before August 30 every year. The Ministry of Finance shall take charge and coordinate with the Ministry of Health to send a consolidated report to the Prime Minister to approve the estimated budget of health insurance-covered medical costs from the estimated revenue and reserve fund for Vietnam Social Security;

b) Based on the estimated budget approved by the Prime Minister, Vietnam Social Security assigns estimated sub-budgets of health insurance-covered medical costs to the Social Security of the Ministry of National Defense, the Social Security of the People's Public Security, and Provincial Social insurance Agencies within 90% of the national health insurance estimated revenues;

c) Based on requests from healthcare facilities, the Provincial Social insurance Agencies shall announce the estimated budget of health insurance-covered medical costs for these facilities. However, these amounts shall not be used as a basis for advances, payments, or settlement of health insurance-covered medical costs if the actual costs exceed the estimates. If the estimated budget of health insurance-covered medical costs for a healthcare facility increases or decreases during the year compared to the announced budget, the facility must submit a document to the Provincial Social Security Agency by October 15th each year for review and adjustment within the Social Security Agency's assigned estimated budget;

d) In case of the total estimated budget for health insurance-covered medical costs at health facilities or  of the Social Security of the Ministry of National Defense, People's Public Security Social Security during the year increases or decreases compared to the estimated budget assigned by Vietnam Social Security, the Provincial Social insurance Agency, Social Security of the Ministry of National Defense, Social Security of People's Public Security shall send a consolidated report to Vietnam Social Security before October 30 every year for adjustments.

Vietnam Social Security shall consider adjusting the estimated budget for Provincial Social Security Agencies, the Social Security of the Ministry of National Defense, the Social Security of the People's Public Security, within the given budget estimate assigned by the Prime Minister before November 15 of each year, so as to adjust the estimated budgets for health facilities.

3. Provide extra budget for health insurance-covered medical costs for a healthcare facility in case their actual medical costs in a year, as assessed by the social insurance agency, exceed both their estimated budget (including the amount announced at the beginning of the year and the adjusted amount during the year) and the budget assigned by Vietnam Social Security as follows:

a) The Provincial Social Security Agency shall take charge and cooperate with the Health Department and the healthcare facility in reviewing medical costs that exceed the estimated budget but are eligible for being repaid, and provide an extra budget for this facility.

b) If the estimated budget assigned by Vietnam Social Security is insufficient for healthcare facilities, the Provincial Social Security Agency, Social Security of the Ministry of National Defense, Social Security of People's Public Security shall send a consolidated report to Vietnam Social Security for consideration of extra budgets.

4. If the actual spending on medical costs in a year exceeds the estimated budget assigned by the Prime Minister, Vietnam Social Security shall provide healthcare facilities with extra budgets from their backup fund, and then send a consolidated report to the Council of Social Security Management, Ministry of Finance, Ministry of Health, and the Prime Minister.

If their backup fund is insufficient to provide extra budgets for Provincial Social Security Agencies, the Social Security of the Ministry of National Defense, the Social Security of the People's Public Security, the relevant authorities shall comply with clause 3 Article 35 of this Decree.

5. Advances, payments, and settlement of health insurance-covered medical costs for healthcare facilities are made quarterly in accordance with Clauses 1 and 2, Article 32 of the Law on Health Insurance.

6. Every year, before October 1, Vietnam Social Security shall make a consolidated report on settlement of health insurance fund for the previous year according to Article 32 of the Health Insurance Law."

10. Amendments to Article 42:

a) Amendments to point g of clause 1:

“g) Regulate and guide the connection of data on results of tests, imaging diagnoses, functional testing, medical therapy of patients who are health insurance policyholders.”;

b) Addition of point i after point h clause 1:

“i) Instruct healthcare facilities and centralized procurement units to rigorously comply with procurement and bidding regulations to ensure the timely supply of health insurance-covered drugs, chemicals, and medical supplies, and to improve cost-effectiveness and prevent waste. Direct healthcare facilities to abide by the laws and regulations on medical examination and treatment, professional guidelines of the Ministry of Health, and relevant procurement and bidding laws to ensure the supply of qualified, effective, and economical medical procedures. Review and update according to practical requirements the lists, conditions, coverage scope and rates for drugs, supplies, medical procedures, and goods within the coverage scope of the health insurance fund to ensure effective management and use of funds.

c) Amendments point d clause 5 Article 42:

“d) Enhance the information technology system to support the timely receipt, assessment, and response to data on health insurance-covered medical examinations and treatment from healthcare facilities; ensure the accuracy, security, and confidentiality of information and the rights of relevant parties; and proactively monitor, detect, and provide timely warnings to health insurance-covered healthcare facilities about increased medical costs compared to the average medical costs of healthcare facilities of the same class, level, and specialty.”

Article 2. Amendments to and annulment of certain regulations of Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government on elaboration of the Law on Health Insurance

1. Amendments to forms No. 5, 6 and 7 in the Appendix issued with Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government on elaboration of the Law on Health Insurance Law with forms No. 5, 6 and 7 in the Appendix issued with this Decree.

2. Annulment of clause 16 Article 3 of Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government on elaboration of the Law on Health Insurance.

3. Annulment of clauses 4, 5 and 6 Article 24 of Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government on elaboration of the Law on Health Insurance.

Article 3. Entry into force

1. This Decree comes into force as of December 3, 2023.

2. Clause 1, Points a and b, Clause 2, Clauses 3, 4, 5 and 6, Article 1 of this Decree apply from October 19, 2023.

3. State budget support for the entities specified in Point c, Clause 2, Article 1 of this Decree for a period of 36 months from November 1, 2023

4. Clause 8, Article 1 and Clause 3, Article 2 of this Decree apply from January 1, 2019. The payment and settlement of health insurance-covered medical costs from January 1 2019 shall comply with the Article 30, Article 31 and Clause 2, Article 32 of the Law on Health Insurance and Clause 8, Article 1 of this Decree.

Article 4. Transitional provisions

Health insurance policyholders who entered healthcare facilities for treatment before the effective date of this Decree but are discharged from the hospital on or after the effective date of this Decree will have their medical costs paid by the health insurance fund within their coverage scope and rates, in accordance with the Law on Health Insurance, Points b, c, d, dd, g, and h of Clause 1, Clauses 2, 3, 4, and 5 of Article 14 of Decree No. 146/2018/ND-CP, and Clause 5 of Article 1 of this Decree.

Article 5. Implementation

Ministers, Heads of ministerial-level agencies, Heads of Governmental agencies, Presidents of People’s Committees of provinces and central-affiliated cities, and relevant entities shall implement this Decree./.