Thông tư 40/2015/TT-BYT quy định đăng ký khám, chữa bệnh bảo hiểm y tế ban đầu và chuyển tuyến khám, chữa bệnh bảo hiểm y tế do Bộ trưởng Bộ Y tế ban hành

CIRCULAR

ON REGISTRATION OF INITIAL MEDICAL EXAMINATION AND TREATMENT AND REFERRALS BETWEEN HEALTH FACILITES COVERED BY HEALTH INSURANCE

Pursuant to the Law on Health insurance No. 25/2008/QH12 dated November 14th 2008 and Law on amendments to the Law on Health insurance No. 46/2014/QH13 dated June 13th 2014;

Pursuant to the Law on medical examination and treatment No. 40/2009/QH12 dated November 23rd 2009;

Pursuant to Decree No. 105/2014/ND-CP dated November 15th 2014 by the Government on guidelines for the Law on Health insurance;

Pursuant to the Decree No. 63/2012/ND-CP dated August 31st 2012 by the Government defining the functions, tasks, entitlements and organizational structure of the Ministry of Health;

At the request of the Director of Department of medical insurance affiliated to the Ministry of Health;

The Minister of Health promulgates a Circular on registration of initial medical examination and treatment and referrals between health facilities covered by health insurance.

Chapter I

GENERAL PROVISIONS

Article 1. Scope

This Circular deals with registration of initial medical examination and treatment (hereinafter referred to as medical services) and referrals between health facilities covered by health insurance.

Article 2. Rules

1. Facilities receiving registration of initial medical services covered by health insurance (hereinafter referred to as initiating facilities) prescribed in this Circular are specified in the referral system of State and equivalent.

2. Each person with health insurance card may take a referral in accordance with regulations on referrals between health facilities according to medical techniques and this Circular.

Chapter II

INITIATING FACILITIES

Article 3. Initiating facilities of communes and equivalent

1. Health facilities of communes, wards and towns (hereinafter referred to as communes);

2. Health facilities of agencies, units and organizations;

3. Private GP/family clinics;

4. Military-civilian health facilities; military- civilian clinics, military health facilities of battalions and other health facilities as prescribed by the Minister of National Defense.

Article 4. Initiating facilities of districts and equivalent

1. Polyclinics of districts, district-level towns and provincial-affiliated cities hereinafter referred to as districts);

2. Medical centers of districts provide medical services; medical centers of districts with polyclinic departments.

3. Polyclinics; local polyclinics;

4. Grade III, grade IV and ungraded polyclinic hospitals affiliated to ministries and agencies or affiliated to units of ministries and agencies;

5. Grade III-equivalent, grade IV-equivalent or ungraded private polyclinic hospitals;

6. Grade III-equivalent, grade IV-equivalent or ungraded private hospitals of traditional medicine;

7. Health facilities affiliated to the Ministry of Public Security and police infirmaries of provinces or central-affiliated cities (hereinafter referred to as provinces);

8. Military-civilian medical centers, military infirmaries, military-civilian infirmaries, grade III, grade IV and ungraded military hospitals, grade III, grade IV and ungraded military-civilian hospitals and other health facilities as prescribed by the Minister of National Defense.

Article 5. Initiating facilities of provinces and equivalent

1. Polyclinic hospitals of provinces;

2. Grade I and grade II polyclinic hospitals affiliated to ministries and agencies or affiliated to units of ministries and agencies;

3. Specialized hospitals, preventive health centers of provinces with polyclinic departments;

4. Hospitals of pediatrics, hospitals of obstetrics and pediatrics of provinces;

5. Grade I-equivalent and grade II-equivalent private polyclinic hospitals;

6. Hospitals of traditional medicine of provinces, ministries or agencies;

7. Grade I-equivalent and grade II-equivalent private hospitals of traditional medicine;

8. Clinics affiliated to Officials’ health care boards of provinces;

9. Grade II hospitals affiliated to the Ministry of National Defense, grade II military- civilian hospitals and other health facilities as prescribed by the Minister of National Defense.

Article 6. Central initiating facilities and equivalent

1. Polyclinic hospitals affiliated to the Ministry of Health, other than hospitals prescribed in Clause 3 of this Article;

2. Specialized hospitals, specialized institutes affiliated to the Ministry of Health with polyclinic departments;

3. Huu Nghi hospital, Da Nang C hospital and Thong Nhat hospital affiliated to the Ministry of Health;

4. Special grade or grade I hospitals affiliated to the Ministry of National Defense, Military Institute of Traditional Medicine and other health facilities as prescribed by the Minister of National Defense.

Article 7. Conditions for initiating facilities

1. Each facility must have an operation license in terms of medical services (hereinafter referred to as operation license).

2. Each medical practitioner must have a practice certificate in terms of medical services.

3. If a health facility specified in clauses 1, 2, 4 and 5 Article 3 of this Circular has no operation license, it must have sufficient personnel, facilities, equipment, ensuring to satisfy normal healthcare demands and provide first aid and emergency care, supply and dispense medicines within professional tasks as prescribed in laws on medical services.

4. Each private GP/family clinics: must satisfy conditions for issuance of licenses for operation applicable to private GP/family clinics prescribed by the Ministry of Health.

5. Each polyclinic must have at least two specialities for internal medicine and surgical medicine; each polyclinic providing pediatric healthcare must also have a pediatric speciality.

Chapter III

REGISTRATION FOR INITIAL MEDICAL SERVICES COVERRED BY HEALTH INSURANCE

Article 8. Registration of initial medical services covered by health insurance at initiating facilities of communes or districts

Each participant of health insurance may register for initial medical services covered by health insurance (hereinafter referred to as initial medical services) at any of the health facilities prescribed in Articles 3 and 4 of this Circular, regardless of administrative division, conformity with his/her work place, place of residence and capacity of the health facility.

Article 9. Registration of initial medical services at initiating facilities of provinces and central health facilities

1. Each participant of health insurance may register for initial medical services at any of health facilities prescribed in Clauses 1, 2, 3, 4, 5, 6, 7 and 9 Article 5 and Article 6 of this Circular in any of the following cases:

a) He/she lives permanently/temporarily for definite time or works in a district that does not have health facilities specified in Articles 3 and 4 of this Circular or has medical facilities unconformable with conditions for initial medical services for participants of health insurance according to regulations of the Director of the Department of Health with consent in writing of the Director of Social Security of province;

b) He/she lives permanently/temporarily for definite time or works in a district may register for initial medical services at health facilities specified in clauses 1, 2, 3, 4, 5, 6, 7 and 9 Article 5 and Article 6 of this Circular according to regulations of the Director of the Department of Health with the consent in writing of the Director of Social Security of province.

2. Each participant of health insurance may register for initial medical services at any of health facilities specified in Article 8, Clause 1 Article 9 of this Circular or register for initial medical services at another medical facility as follows:

a) Each person eligible for of health management and healthcare services according to the Guidance No. 52/HD/BTCTW dated 02/12/2005 by Central Organization Board of Communist Party on supplements of entities eligible for medical services at some health facilities may register for initial medical services at Huu Nghi Hospital, Da Nang C Hospital or Thong Nhat Hospital affiliated to the Ministry of Health or other health facilities specified in Article 5 (excluding Clause 4) and Clauses 1, 2 and 4 Article 6 of this Circular;

b) Each person eligible for health management and healthcare services for officials of provinces may register for initial medical services at clinics affiliated to Officials’ health care boards of provinces or health facilities specified in clauses 1, 2, 3, 5, 6, 7 and 9 Article 5 of this Circular;

c) Each person meritorious to the revolution, person aged 80 or older may register for initial medical services at health facilities specified in clauses 1, 2, 3, 5, 6, 7 and 9 Article 5, clauses 1, 2 and 4 Article 6 of this Circular;

d) Kids under 6 may register for initial medical services at health facilities specified in clauses 1, 2, 4 and 5 Article 5 of this Circular;

dd) Each member of military forces who retires may register for initial medical services at any of health facilities specified in Clause 9 Article 5 and Clause 4 Article 6 of this Circular.

3. Each participant of health insurance who is living in island commune/island district may register for initial medical services at the most convenient health facility in mainland, in case there are not any health facility specified in Articles 3, 4, 5 and 6 of this Circular on such island commune/island district.

Chapter IV

REFERRALS IN MEDICAL EXAMINATION AND TREATMENT COVERRED BY HEALTH INSURANCE

Article 10. Referrals in medical examination and treatment covered by health insurance

The referrals in medical services shall comply with Circular No. 14/2014/TT-BYT dated April 14, 2014 of the Ministry of Health on referrals between health facilities according to medical techniques, except for particular cases prescribed in Article 11 of this Circular.

Article 11. Appropriate referrals

1. Each holder of health insurance card who registered for initial medical services at health facilities of communes or polyclinics or hospital of districts may get medical services at health stations of communes, polyclinics or hospitals of districts in the same province.

2. Each holder of health insurance card who registered for initial medical services at a health facility of commune may take a referral to a hospital of district, including grade I, II hospitals of district and hospitals of traditional medicine of province (if the hospital of district has no department of traditional medicine).

3. Each holder of health insurance card may take a referral from a hospital of district, including grade I, grade II hospital and polyclinic hospital, specialized hospital, specialized institute, specialized center of province, to a specialized center of province or polyclinic hospital, specialized hospital, specialized institute of province at the same level or lower level.

4. Emergency cases:

a) A patient shall be given emergency treatment at any health facilities. The doctor or physician assistant receiving the patient shall assess the emergency conditions and record in medical record.

b) After emergency treatment, the patient shall be admitted as an inpatient to the receiving facility or referred to another health facility for continuing treatment at the specialist requirements or referred to the original facility upon his/her rehabilitation.

5. In case the referred patient has another disease already, or a disease that is diagnosed apart from the disease specified in the outward referral form, the receiving facility shall give treatment to those diseases within its capacity.

6. When a holder of medical insurance card goes on a business trip, studies, works or resides temporarily for a period of under 12 months in another administrative division, he/she is eligible for medical services at a health facility in the administrative division at the same level with the initiating facility specified in his/her health insurance card. If that administrative division has no equivalent heath facility, the holder of health insurance card may choose another heath facility providing initial medical services.

Article 12. Using outward referral forms and follow-up appointment forms in medical services

1. Outward referral forms for patients having health insurance cards:

a) If a patient is referred to another heath facility, he/she is only required an outward referral form made by the heath facility that directly makes the referral.

b) In case a patient arrives at a heath facility other than his/her initiating heath facility and he/she is referred to another health facility, he/she is only required an outward referral form of the heath facility that directly makes the referral.

c) Each outward referral form shall be valid within 10 working days, from the day on which it is signed;

d) With regard to patients having health insurance cards that suffer from diseases, groups of disease and those eligible for using the outward referral form prescribed in Appendix 1 issued herewith, their outward referral forms shall be valid until December 31 of such calendar year. In case where a patient mentioned above, at the end of December 31 of the year, still be an inpatient in the health facility, his/her outward referral form only be valid until the end of such impatient treatment.

2. Follow-up appointment forms: Each follow-up appointment form shall be used only one time according to the mentioned time. The follow-up appointment form for patients covered by medical insurance shall be prescribed in Appendix enclosed herewith.

Chapter V

IMPLEMENTATION

Article 13. Responsibilities of the Department of Health

1. Preside over, cooperate with social security of provinces, health facilities affiliated to the Ministry of Health and ministries and agencies having offices located in their provinces to:

a) Determine and make a list of medical facilities eligible for providing initial medical services in administrative divisions of the provinces;

b) Provide guidance on the registration for initial medical services for entities specified in Clause 3 Article 9 of this Circular;

b) Provide guidance on the registration for initial medical services for children aged under specified in Point d Clause 2 Article 9 of this Circular.

d) Provide guidance on the referrals between health facilities for participants of health insurance according to the law provisions.

2. Preside over, cooperate with social security of provinces, health facilities affiliated to the Ministry of Health and relevant ministries and agencies in imposing regulations on entities, proportion of groups of entities, number of participants in health insurance that register for initial medical services specified in Articles 8 and 9 of this Circular according to the actual conditions of their provinces and capability of health facilities.

3. Preside over, cooperate with social security of provinces in imposing regulations on entities, proportion of groups of entities, number of participants in health insurance that register for initial medical services at specialized institutes, centers and hospitals, hospitals and institutes of traditional medicine conformable with the actual conditions of health facilities and the system of health facilities in the administrative divisions, facilitate the use of personnel, facilities and equipment within and quality of care.

4. Direct the affiliated health facilities to implement the regulations in this Circular.

Article 14. Responsibilities of social security of provinces

1. Conclude contracts for medical services covered by health insurance with health facilities eligible for providing initial medical services according to the list approved by the Department of Health.

2. Cooperate with the Department of Health in providing guidelines for registration and change of initiating facilities in the provinces in accordance with this Circular.

3. Provide guidance on medical services for holders of health insurance card prescribed in Clause 6 Article 11 of this Circular.

Article 15. Responsibilities of health facilities affiliated to Ministries and agencies

1. Military Medical Department - the Ministry of National Defense, Health Department - the Ministry of Public Security:

a) Direct and guide health facilities affiliated to the Ministry of National Defense and the Ministry of Public Security eligible for providing initial medical services to register with the Department of Health of provinces;

b) Provide guidance on registration of initial medical services and provisions of medical services at health facilities affiliated to the Ministry of National Defense and the Ministry of Public Security.

2. Health facilities of other ministries and agencies:

a) Direct health facilities affiliated to the ministries and agencies eligible for providing initial medical services to register with the Department of Health of provinces;

b) Provide guidance on registration of initial medical services and provisions of medical services at health facilities as prescribed.

Article 16. Responsibilities of health facilities

1. Provide medical services, make referrals to other health facilities and ensure the interests of participants of health insurance as prescribed.

2. According to actual conditions of the facility, the head of the facility shall assign a person in charge of prompt receipt of referred patients in or out of office hours.

Chapter VI

IMPLEMENTATION

Article 17. Effect

1. This Circular comes into effect from January 1, 2016.

2. Circular No. 37/2014/TT-BYT dated November 17, 2014 of the Minister of Health on guidelines for registration of initial medical services and referrals shall be annulled from the effective date of this Circular.

Article 18. Transitional provision

Each participant in health insurance who has registered for initial medical services at the facility written on the health insurance card before the effective date of this Circular shall be continue receiving medical services at such facility until there is modification of the registered initial medical facility according to the guidance in this Circular.

Article 19. Terms of reference

In case the documents referred to in this Circular are replaced or amended, they shall prevail.

Difficulties that arise during the implementation of this Circular should be reported to the Ministry of Health./.

APPENDIX 1

LIST OF DISEASES, GROUPS OF DISEASES AND CASES USING OUTWARD REFERRAL FORMS IN THE CALENDAR YEAR 
(Issued together with Circular No. 40/2015/TT-BYT dated November 16, 2015 of the Minister of Health)

Notes: (*) are names of diseases and groups of diseases prescribed in Circular No. 34/2013/TT-BYT dated October 28, 2013 of the Minister of Health on issuance of List of diseases requiring long-term treatment.