Chương III Thông tư 30/2020/TT-BYT: Chuyển đổi mức hưởng bảo hiểm y tế, thanh toán chi phí khám bệnh, chữa bệnh bảo hiểm y tế của một số đối tượng

Chapter III

CONVERSION OF HEALTH INSURANCE LEVEL, PAYMENT OF MEDICAL EXAMINATION AND TREATMENT COSTS COVERED BY HEALTH INSURANCE OF CERTAIN INDIVIDUALS

Article 5. Conversion of health insurance level for specific individuals

1. In case a beneficiary is eligible for multiple health insurance modes where code of level of benefit shown on his/her health insurance card is not specifying the highest mode, he/she shall be converted to the highest mode as soon as documents under Clauses 2, 3, and 4 of this Article are available.

2. Documents proving that health insurance participants are people with meritorious services to the revolution, except for war veterans under Clause 3 of this Article; relatives of people with meritorious services to the revolution, people nurturing martyrs:

Conform to Article 5 of Circular No. 30/2019/TT-BLDTBXH dated December 26, 2019 of Ministry of Labor - War Invalids and Social Affairs providing guidelines on producing lists of health insurance participants under management of Ministry of Labor – War Invalids and Social Affairs, to be specific:

a) People with meritorious services to the revolution: rely on Decision on acknowledgement of competent agencies or Decisions on processing policies of Directors of Departments of Labor, Invalids and Social Affairs of provinces and central-affiliated cities;

b) Relatives of people with meritorious services to the revolution, people nurturing martyrs: rely on Decisions on processing policies of Directors of Departments of Labor, Invalids and Social Affairs of provinces and central-affiliated cities; in case of no decisions available, rely on list of benefit payment for people with meritorious services to the revolution and relatives thereof.

3. Documents proving that health insurance participants are war veterans:

a) In case of war veterans leaving, discharged from the army, rely on one of the following documents:

- Decisions on demobilization, discharge (dismissal);

- Official personal background sheet or Excerpt No. 63 of officers;

- Servicemen personal background sheet;

- Servicemen card;

- Servicemen background sheet;

- Background sheet of member of the Communist Party produced before the date on which the servicemen leave or are discharged (dismissed);

- Decision on receiving benefits as per the law under any of the following documents:

+ Decree No. 500-ND/LB dated November 12, 1958 of joint Ministry of National Defense, Ministry of Finance and Ministry of Social Support on rules for long-term benefits for voluntary servicemen discharged due to inability to work as a result of illnesses.

+ Decree No. 111-ND dated June 22, 1957 of Ministry of National Defense on elaborating to benefits for discharged servicemen;

+ Decision No. 47/2002/QD-TTg dated April 11, 2002 of the Prime Minister on policies on servicemen and national defense employees participating in resistance war against France discharged (dismissed, retired) prior to December 31, 1960;

+ Decision No. 290/2005/QD-TTg dated November 8, 2005 of Prime Minister on policies on individuals participating in resistance war against America without receiving policies of the Communist Party and the Government;

+ Decision No. 188/2007/QD-TTg dated December 6, 2007 of the Prime Minister on amendment to Decision No. 290/2005/QD-TTg dated November 8, 2005 of the Prime Minister;

+Decision No. 142/2008/QD-TTg dated October 27, 2008 of the Prime Minister on implementation of policies on servicemen participating in the resistance war against America discharged, dismissed with under 20 years of service in the army;

+ Decision No. 38/2010/QD-TTg dated May 6, 2010 of the Prime Minister on amendment to Decision No. 142/2008/QD-TTg dated October 27, 2008 of the Prime Minister;

+ Decision No. 62/2011/QD-TTg dated November 9, 2011 of Prime Minister on benefits for individuals participating in war for defending the country, participating in international missions in Cambodia, assisting Laos after April 30, 1975 who have been demobilized, discharged or retired.

b) War veterans retiring, receiving monthly social benefits: rely on Decisions on receiving monthly pension or Decisions on receiving monthly social benefits issued by competent agencies.

c) War veterans who have reassigned shall rely on any of the following documents:

- Decisions on demobilization, discharge (dismissal), reassignment;

- Official personal information background sheet or Excerpt No. 63 of officers;

- Servicemen personal background sheet;

- Servicemen card;

- Servicemen background sheet;

- Personal background of national defense employees;

- Background sheet of member of the Communist Party produced before the date on which the servicemen leave or are discharged (dismissed), reassigned;

 d) In case war veterans lose documents:

- War veterans who lose documents proving war veteran status but instead obtain any of the following documents:

+ Decision on enlistment;

+ Decisions on employment;

+ Decision on promotion, pay raise;

+ Decision mobilization, assignment;

+ Documents rewarding for merits in resistance war, rewarding for participation in the war;

+ Documents confirming war veteran status of People’s Committees of communes where the beneficiaries reside according to Point b Clause 7 Article 2 of Decree No. 150/2006/ND-CP dated December 12, 2006 of the Government on elaborating to Ordinance on War Veterans (applicable to individuals obtaining documents issued before December 29, 2006 which prove their status as war veterans).

- War veterans enlisted after April 30, 1975 who fought, served the war directly but lost documents proving their status as war veterans: Written confirmation of their participation in national defense war issued by heads of their units according to Article 6 of Joint Circular No. 01/2012/TTLT-BQP-BLDTBXH-BTC dated January 5, 2012 of joint Ministry of National Defense, Ministry of Labor – War Invalids and Social Affairs, Ministry of Finance guiding implementation of Decision No. 62/2011/QD-TTg dated November, 2011 of Prime Minister on policies for individuals participating in national defense war, international missions in Cambodia, assisting Laos after April 30, 1975 and have been demobilized, discharged or retired as the basis for verifying war veteran status;

- War veterans enlisted after April 30, 1975 who directly fought, served the war, and obtained documents which do not specify time, unit, location of service: Excerpt from presentation regarding units, time and location of service during national defense war issued by Commanding Officers of Military Commands of districts where the veterans reside according to Guidelines No. 3386/LC-CTC-CCS dated November 15, 2012 of joint Department of Operations, Department of Policies guiding implementation of Decision No. 2084/QD-BBTM dated November 9, 2012 of Chief of the General Staff on issuance of list of locations, time and units directly fighting national defense war and participating in international missions after April 30, 1975.

4. Other beneficiaries:

Rely on documents proving eligibility for receiving benefits at a level higher than the level they are currently benefitting from issued by their superior agencies.

Example: Mr. Nguyen Van A is a serviceman serving national defense war in the northern border, was discharged in 1980 and later enters into employment contract with Company B, participates in health insurance for employees (benefit level according to health insurance card is 80%).  

As soon as Mr. A provides Decision on discharge, he is determined eligible for health insurance for war veterans. In such case, social security agency shall re-issue health insurance card, convert benefit level of Mr. A from 80% to 100% with limits on percentage of payment for certain medicines, chemicals, medical materials, medical technical service conforming to regulations of Minister of Health.

5. The new benefit level of health insurance of beneficiaries under Clauses 2, 3, and 4 of this Article shall start from the date on which the new health insurance card is effective on information system of social security agencies. Social security agencies are responsible for informing beneficiaries of upgraded benefit level as soon as the new benefit level comes into effect on the information system.

Article 6. Medical examination and treatment under health insurance in appropriate level

Cases of receiving medical examination and treatment under health insurance include:

1. Health insurance participants apply for medical examination and treatment in initial medical examination and treatment establishments specified on their health insurance cards.

2. Health insurance participants who apply for initial medical examination and treatment in medical examination and treatment establishments of communes or general clinics or district hospitals may receive medical examination and treatment covered by health insurance in other medical stations of communes or general clinics or district hospitals in the same provinces.  Children who have not obtained health insurance cards since birth declaration procedures have not been adopted may use birth certificates to receive medical examination and treatment in medical examination and treatment establishments specified under this Clause.

3. Health insurance participants who are in state of emergency are provided with emergency medical aid in any medical examination and treatment establishment in the country.

Doctors or physicians shall assess and identify state of emergency of the patients, specify in patients’ medical records and be responsible for their decisions.

4. Health insurance beneficiaries who benefit from transfer of administrative levels for receiving medical examination and treatment under health insurance as per the law, including:

a) May transfer according to Article 10 and Article 11 of Circular No. 40/2015/TT-BYT dated November 16, 2015 of Minister of Health on registration for initial medical examination and treatment under health insurance and transfer of administrative level for receiving medical examination and treatment under health insurance. Applications for transfer consist of transfer documents using Form No. 6 attached to Decree No. 146/2018/ND-CP and other documents (if any);

b) May transfer according to Clause 3 Article 14 of Decree No. 146/2018/ND-CP, including: emergency medical aid; cases where beneficiaries are diagnosed with other diseases exceeding the specialty of medical examination and treatment establishments during inpatient treatment process; disease development exceeds capacity of medical examination and treatment establishments during inpatient or outpatient treatment process;

c) May transfer according to Clause 2 Article 6 of Circular No. 04/2016/TT-BYT dated February 26, 2016 of Minister of Health on elaborating to medical examination, treatment and payment for medical examination, treatment covered by health insurance relating to examination and treatment of tuberculosis.

5. Health insurance participants who obtain documents proving their stay in other administrative divisions when they go on working trips, participate in concentrated education in training programs, semi-boarding programs and apply for initial medical examination, treatment in medical examination and treatment establishments of the same or equivalent administrative level as their initial medical examination and treatment establishments specified on health insurance cards according to Clause 7 Article 15 of Decree No. 146/2018/ND-CP. Medical examination and treatment establishments are responsible for storing photocopy of documents specified under this Point in medical records of beneficiaries.

6. Holders of notice of re-examination appointment in case they have been transferred according to Clause 5 Article 15 of Decree No. 146/2018/ND-CP.

7. Individuals who have donated their organs and require immediate treatment after donating organs.

8. Newborn babies who must receive treatment upon birth.

Article 7. Payment of medical examination and treatment costs in case of individuals who have donated their organs

1. Healthcare Insurance Fund (HIF) shall pay for medical examination and treatment of individuals who have donated their organs according to regulations and law on donating, harvesting, grafting tissues, human organs and donating, collecting corpses in case immediate treatment is required as soon as surgeons complete technical procedures for extracting organs of donors.

2. The HIF shall not pay for medical examination and treatment costs that have been included in costs for collecting organs of donors or costs that have been paid for by other financial sources.

3. Medical examination and treatment establishments that adopt technical procedures for collecting organs of donors are responsible for:

a) consolidating list of donors and costs for medical examination and treatment and sending to social security agencies for payment as per Clause 4 Article 15 of Decree No. 146/2018/ND-CP;

b) excerpting and transferring electronic data according to Clause 2 Article 10 hereof.

Article 8. Guidelines for providing medical examination and treatment under health insurance in initial healthcare

1. Medical examination and treatment practitioners, other than testing personnel, X-ray technicians, physical therapy technicians and midwives, may provide initial healthcare in education institutions or vocational education institutions, agencies, organizations and enterprises (hereinafter referred to as “agencies”) on a full-time or part-time basis according to Point a Clause 1 Article 34 of Decree No. 146/2018/ND-CP as soon as they obtain any of the following documents:

a) Written assignment in case practitioners are officials or employees of agencies;

b) Written agreement in case practitioners are not specified under Point a of this Clause.

2. Written agreement specified under Point b Clause 1 of this Article must contain the following basic information:

a) Employer of part-time medical examination and treatment practitioner: Name and address of agency; full name of head of the agency; phone number;

b) Provider of part-time medical examination and treatment in initial healthcare: Full name, date of birth, gender, residence address, ID Card number or other legitimate documents; phone number in case of signing written agreements with practitioners or name, address, full name of head of medical examination and treatment establishment in case of signing written agreements with medical examination and treatment establishments;  

c) Task details, working locations and working time, where working time shall be agreed upon by the employer and the provider;

d) Implementation period of written agreements (in financial year or school year);

dd) Commitment of the employer and provider regarding assuming legal responsibilities for agreement details and task implementation results.

3. Written agreement shall only be signed by agencies with medical examination and treatment establishments or with part-time medical examination and treatment practitioners in initial healthcare when:

A) Medical examination and treatment establishments are located in the same communes as the agencies or in communes adjacent to communes where the agencies are based; or

b) Medical examination and treatment practitioners register for practice during office hours in communes where the agencies are based or in communes adjacent to communes where the agencies are based.

Article 9. Transfer for provision of subclinical service

1. Transfer for provision of subclinical services shall be implemented in a manner conforming to technical requirements in medical examination and treatment, ensuring benefits of health insurance beneficiaries and applicable to the following services:

a) Subclinical services which are under list of medical technical services approved by competent authorities for medical examination and treatment establishments, currently being provided in medical examination and treatment establishments but cannot be implemented by the medical examination and treatment establishments when the services are designated for the patients;

b) Subclinical services which are not under list of medical technical services approved by competent authorities for medical examination and treatment establishments but are necessary for specialized activities according to regulations of Minister of Health on management, diagnosis and treatment in medical examination and treatment shall be paid by the HIF for cases of patients receiving inpatient treatment in district level hospitals or higher.

Heads of medical examination and treatment establishments accepting health insurance shall rely on functions, tasks and scope of specialized operations approved by competent authorities to produce list of subclinical services that require transfer and send to social security agencies where contracts for provision of medical examination and treatment under health insurance are signed to enable both parties to add annexes thereto prior to implementation.

2. Medical examination and treatment establishments may only transfer patients or specimen to establishments approved by competent authorities to be eligible for provision of subclinical services and must sign contracts on provision principles with subclinical service providers (contracts must include the fact that social security agencies where contracts for provision of medical examination and treatment under health insurance are signed have assessed subclinical services received and provided in subclinical service providers).

3. Subclinical service providers, after receiving patients or specimen in order to perform subclinical services, must not transfer the patients and specimen to another establishment.

4. Encoding of subclinical services:

Medical examination and treatment establishments that transfer patients or specimen (hereinafter referred to as “transferors”) shall encode as follows: XX.YYYY.ZZZZ.K.WWWWW, in which:

a) XX.YYYY.ZZZZ is code of subclinical services;

b) K means subclinical services are provided by other service providers;

c) WWWWW means code of subclinical service providers issued by Ministry of Health.

5. Payment:

a) Payment of costs for provision of subclinical services shall conform to Clause 6 Article 27 of Decree No. 146/2018/ND-CP and conform to price of service providers receiving transferred patients or specimen without exceeding medical examination and treatment costs specified under Circular No. 13/2019/TT-BYT dated July 5, 2019 of Minister of Health on amendment to Circular No. 39/2018/TT-BYT dated November 30, 2018 of Minister of Health on costs for medical examination and treatment covered by health insurance among hospitals on the same administrative level and guidelines for application and settlement of costs for medical examination and treatment covered by health insurance in some cases.

In case a subclinical service is provided by multiple service providers simultaneously, the HIF shall only pay for a single provision of the subclinical service.

b) Subclinical service providers receiving transferred patients and specimen must not charge the patients additional costs for medical examination and provision of subclinical services.

Article 10. Application of information technology in management, assessment and payment of medical examination and treatment costs covered by health insurance for certain cases

1. In case of children who benefit from health insurance right upon birth according to Law on Health Insurance but have not been issued with health insurance cards by social security agencies due to incompletion of birth declaration procedures, medical examination and treatment establishments shall:

a) produce provisional health insurance cards, consisting of:

- Beneficiary code: specify TE;

- Health insurance benefit code: specify number 1;

- Code of provinces and central-affiliated cities: specify according to Decision No. 124/2004/QD-TTg dated July 8, 2004 of the Prime Minister on list and code of administrative divisions of Vietnam (hereinafter referred to as “Decision No. 124/2004/QD-TTg”) where the mothers or legal guardians reside or where medical examination and treatment establishments are based in case of newborn babies abandoned in medical examination and treatment establishments;

- Medical ID code: specify according to Decision No. 2153/QD-BYT date May 25, 2020 of Minister of Health on Regulations on establishing, using and managing medical ID code (hereinafter referred to as “Decision No. 2153/QD-BYT”).

Example: Provisional code for a child receiving medical examination and treatment whose mother resides in Hanoi shall be encoded as: TE101 and followed by medical ID code (10 digits).

b) Specify name of newborn babies who have not been named in medical records for medical examination and treatment, extraction and transfer of electronic data serving management, assessment and payment of medical examination and treatment costs covered by health insurance as follows:

- If a newborn baby is accompanied by either parent: specify full name of that parent;

- If a new born baby is not accompanied by any parent but by a guardian: specify full name of the guardian;

- If a newborn baby is not accompanied by anyone or is abandoned in a medical examination and treatment establishment: specify name of the medical examination and treatment establishment that is currently providing treatment.

2. In case individuals who have donated their organs have not been issued with health insurance cards by social security agencies, medical examination and treatment establishments shall produce provisional health insurance cards to extract, transfer electronic data and serve management, assessment and payment of medical examination and treatment under health insurance and:

a) Beneficiary code: specify HG;

b) Benefit code: specify number 4;

c) Code of provinces and central-affiliated cities: specify according to Decision No. 124/2004/QD-TTg where the donors reside;

d) Medical ID code: specify according to Decision No. 2153/QD-BYT.

Example: in case of a donor residing in Hanoi, encode as follow: HG401 followed by medical ID code (10 digits).

3. Medical examination and treatment establishments shall send data requested for assessment and payment of medical examination and treatment costs covered by health insurance of beneficiaries under management of Politburo, Secretariat in writing until new regulations, guidelines on extraction and transmission of electronic data are issued; data on consolidated costs for medical examination and treatment covered by health insurance of these beneficiaries using Form No. C79-HD attached to Circular No. 102/2018/TT-BTC dated November 14, 2018 of Ministry of Finance guiding accounting affairs for social security.  

Article 11. Immediate suspension or termination of health insurance cards

1. Social security agencies shall immediately suspend, terminate health insurance cards on their information system for health insurance beneficiaries as follows:

c) In case health insurance beneficiaries decease in medical examination and treatment establishments, social security agencies shall immediately suspend, terminate health insurance cards of the deceased beneficiaries after receiving electronic data where field 22 (KET_QUA_DTRI) of Schedule 1 attached to Decision No. 4210/QD-BYT dated September 20, 2017 of Minister of Health contains a “5” transferred by medical examination and treatment establishments to data receipt portal within information system of social security agencies;

b) In case health insurance beneficiaries decease outside of medical examination and treatment establishments, social security agencies shall immediately suspend, terminate health insurance cards of the deceased beneficiaries as soon as People’s Committees of communes where the deceased health insurance beneficiaries reside issue notice on information system of social security agencies.

2. If medical examination and treatment establishments incur medical examination and treatment costs covered by health insurance and request payment after the medical examination and treatment establishments have extracted and transmitted data to data receipt portal within information technology system of social security agencies according to Point a Clause 1 of this Article or after People’s Committees of communes where deceased health insurance beneficiaries reside have issued death certificates and uploaded on information systems of social security agencies according to Point b Clause 1 of this Article, proceed as follows:

a) The HIF shall pay for medical examination and treatment costs covered by health insurance according to Article 4 of Circular no. 09/2019/TT-BYT dated June 10, 2019 of Minister of Health guiding inspection of conditions for signing contracts for initial medical examination and treatment under health insurance, transfer for provision of subclinical services and cases of direct cost settlement in medical examination and treatment under health insurance in case of health insurance card’s error or faulty information update by medical examination and treatment establishments or People’s Committees of communes;

b) The HIF shall not pay for medical examination and treatment costs covered by health insurance occurred as a result of relatives of the deceased health insurance beneficiaries or other individuals use health insurance cards for the deceased beneficiaries; social security agencies shall consolidate and request competent authorities to take actions against violating individuals as per the law.