Thông tư 09/2019/TT-BYT hướng dẫn thẩm định điều kiện ký hợp đồng khám bệnh, chữa bệnh bảo hiểm y tế ban đầu, chuyển thực hiện dịch vụ cận lâm sàng và một số trường hợp thanh toán trực tiếp chi phí trong khám bệnh, chữa bệnh bảo hiểm y tế do Bộ trưởng Bộ Y tế ban hành

CIRCULAR

PROVIDING INSTRUCTIONS FOR ASSESSMENT OF REQUIREMENTS FOR SIGNING CONTRACTS FOR INSURED PRIMARY HEALTHCARE SERVICES, REFERRAL OF SUBCLINICAL SERVICES AND CERTAIN CASES OF DIRECT PAYMENT OF INSURED HEALTHCARE SERVICE COSTS

Pursuant to the Law on Health Insurance dated November 14, 2008 amended and supplemented by the Law on Health Insurance dated June 13, 2014;

Pursuant to the Government's Decree No. 146/2018/ND-CP dated October 17, 2018, elaborating and providing guidance on the implementation of a number of articles of the Law on Health Insurance;

Pursuant to the Government's Decree No. 75/2017/ND-CP dated June 20, 2017, defining the functions, tasks, powers and organizational structure of the Ministry of Health;

The Minister of Health hereby promulgates the Circular providing instructions for assessment of requirements for signing contracts for insured primary healthcare services, referral of subclinical services and certain cases of direct payment of insured healthcare service costs.

Article 1. Scope

This Circular shall provide instructions on insured healthcare services with regard to:

1. Assessment of conformance of healthcare establishments to eligibility requirements for signing insured primary healthcare service contracts.

2. Referral of subclinical diagnostic tests, medical imaging and functional assessment services (hereinafter referred to as subclinical services).

3. Direct payment of insured healthcare service costs made in other special cases defined in point c of clause 1 of Article 31 in the Law on Health Insurance amended and supplemented under the provisions of the Law No. 46/2014/QH13.

Article 2. Assessment of conformance of healthcare establishments to eligibility requirements for signing insured primary healthcare service contracts

1. Assessment of conformance of healthcare establishments to eligibility requirements for signing insured primary healthcare service contracts which is made with respect to healthcare establishments in the lists of healthcare establishments issued by the Departments of Health in accordance with Article 13 in the Circular No. 40/2015/TT-BYT dated November 16, 2015 of the Minister of Health on registration for insured primary healthcare services and referral of insured healthcare services shall only be required in the following cases:

a) Initial request for signing of insured primary healthcare service contract;

b) After termination of insured primary healthcare service contract. 

2. Assessment contents:

a) Comparison of application package for signing of insured primary healthcare service contract with regulations laid down in clause 1 of Article 16 in the Government’s Decree No. 146/2018/ND-CP dated October 17, 2018, elaborating and providing instructions on implementation of certain articles of the Law on Health Insurance (hereinafter referred to as Decree No. 146/2018/ND-CP);

b) Comparison of information about the lists of licensed practitioners working for healthcare establishments with the lists of licensed practitioners published on the Web Portal of the Ministry of Health or the Web Portals of Departments of Health.  

3. Social Security services at provinces and centrally-affiliated cities shall be responsible for making assessments in accordance with clause 2 of this Article within the time limits specified in point b of clause 1 of Article 18 in the Decree No. 146/2018/ND-CP.

Article 3. Referral of subclinical services

1. Referral of subclinical services shall adhere to the principles of conformity with healthcare-related technical requirements, assurance of legitimate rights and interests of health insurance policyholders and consistency with the following lists:

a) Subclinical services in the list of healthcare-related technical services that are approved by competent state authorities for use and currently in use at healthcare establishments but are beyond their capacity at the time when patients are prescribed these services; 

b) Subclinical services not in the list of healthcare-related technical services that are approved by competent state authorities for use at healthcare establishments but, in reality, are necessary for other medical services under the regulations of the Minister of Health on medical management, diagnosis and treatment.

2. Healthcare establishments shall only be allowed to refer patients or pathology specimens to receiving healthcare establishes accredited by competent entities for provision of subclinical services and shall be required to sign agreements in principle with subclinical service providers (the agreement in principle must agree that social security services as signatories to insured healthcare service contracts can assess subclinical services already received and rendered at subclinical service providers).

3. Healthcare establishments receiving patients or pathology specimens used as a basis to render subclinical services shall not be entitled to refer patients or pathology specimens to other third-party healthcare establishments.

4. Encryption of subclinical services:

Healthcare establishments sending patients or pathology specimens (hereinafter referred to as sending healthcare establishments) shall encode subclinical services in the following syntax: XX.YYYY.ZZZZ.K.WWWWW, including:

a) XX.YYYY.ZZZZ stands for the subclinical service;

b) The letter “K” stands for the subclinical service rendered by another healthcare establishment;

c) WWWWW is the set of alphabetical symbols standing for the code of the healthcare establishment assigned by the Ministry of Health. 

5. Service cost payment:

a) Payment of costs of subclinical services shall be subject to regulations laid down in clause 6 of Article 27 in the Decree No. 146/2018/ND-CP and shall be made at the prices quoted by healthcare establishments receiving patients or pathology specimens but restricted to the prices of healthcare services specified in the Circular No. 39/2018/TT-BYT dated November 30, 2018 of the Minister of Health, prescribing uniform prices of insured healthcare services applied at same-level hospitals nationwide and providing instructions on application of prices, payment of insured healthcare service costs in certain cases.

If a subclinical service is implemented at multiple receiving healthcare establishments as required by a prescription, the health insurance fund shall cover costs incurred from a single time of receipt of that service.

b) Upon rendering such service, the receiving healthcare establishment shall not be allowed to collect any other medical costs related to such service from the patient.

Article 4. Direct payment of insured healthcare service costs made in other special cases defined in point c of clause 1 of Article 31 in the Law on Health Insurance amended and supplemented under the provisions of the Law No. 46/2014/QH13

1. Other than cases of direct payment of medical costs prescribed in point a and b of clause 2 of Article 31 in the Law on Health Insurance amended and supplemented under the provisions of the Law No. 46/2014/QH13, health insurance cardholders shall be directly paid medical and healthcare costs in the following cases:

a) A patient has participated in the health insurance plan for at least 5 consecutive years, has paid a co-payment amount greater than 6 months' statutory pay rate in the year (except self-referrals to other out-of-network healthcare establishments) and has not received the refund of the amount in excess to 6 months' statutory pay rate;

b) Health insurance card data are not provided or are provided inaccurately;

c) If the patient does not present his/her health insurance card prior to medical discharge, refer to another healthcare establishment within a day due to medical emergency, loss of consciousness, death or loss of the health insurance card without having it reissued yet.  

2. The social security service receiving application documentation for direct payment shall be responsible for paying insured healthcare service costs for cases specified in clause 1 of this Article at the insurance coverage rate falling in the scope of entitlement to health insurance benefits of health insurance policyholders.

Article 5. Entry into force

This Circular shall enter into force on August 01, 2019.

Article 6. Reference provision

In case where referents mentioned in this Decree are replaced, revised or amended, the substitute or revised document shall prevail.

In the course of implementation of this Circular, if there is any difficulty that arises, entities, organizations and individuals involved should promptly inform the Ministry of Health (Health Insurance Department) for consideration./.