Thông tư liên tịch 41/2014/TTLT-BYT-BTC hướng dẫn thực hiện bảo hiểm y tế do Bộ trưởng Bộ Y tế - Bộ Tài chính ban hành

JOINT CIRCULAR

GUIDANCE ON HEALTH INSURANCE 

Pursuant to the Law on Health Insurance dated November 14, 2008 and the Law on amendments and supplements to a number of articles of the Law on Health Insurance dated June 13, 2014;

Pursuant to the governmental Decree No. 105/2014/NĐ-CP dated November 15, 2014 detailing and guiding the implementation of a number of articles of the Law on Health Insurance ;

Pursuant to the governmental Decree No. 63/2012/NĐ-CP dated August 31, 2012 defining the functions, tasks, powers and organizational structure of the Ministry of Health;

Pursuant to the governmental Decree No. 215/2013/NĐ-CP dated December 23, 2013 defining the functions, tasks, entitlements and organizational structure of the Ministry of Finance;

The Minister of Health and the Ministry of Finance promulgate this joint circular providing guidance on the implementation of health insurance.

Chapter I

PARTICIPANTS, MANNER AND RESPONSIBILITY FOR PAYMENT OF HEALTH INSURANCE PREMIUMS

Article 1. Participants in health insurance

As defined in Article 12 amending and supplementing the Law on Health Insurance; Articles 15, 21, 25 and 26 amending and supplementing the Ordinance on Incentives for Contributors to the Revolution and Article 1 of the Decree No. 105/2014/NĐ-CP, the participants in health insurance (hereinafter referred to as participants) shall include:

1. Participants as employees and employers, including:

a) Permanent employees or employees with a pre-determined period of employment from three months and over; business entrepreneurs, non-public service providers and paid managers of cooperatives; officials and civil servants (hereinafter referred to as employees) working for agencies, organizations and enterprises as follows:

- Regulatory agencies, the people’s armed forces;

- Political organizations, socio-political organizations, and socio-political and occupational organizations;

- Public and non-public service providers;

- Enterprises of economic sectors established and operated under the Law on Enterprise and the Law on Investment;

- Agencies, foreign organizations, international organizations operating within the territory of Vietnam;

- Cooperatives, cooperative alliance established and operated under the Law on Cooperatives;

- Business households, organizations and individuals hiring workforce with labor contracts.

b) Casual workers in communes, wards and towns according to the provisions of law.

2. Participants paid for by the social insurance organization, including:

a) Persons on a monthly pension, benefit for loss of capacity for work;

b) Persons entitled to monthly social insurance benefit due to occupational accidents, occupational diseases or any illness of long-term treatment; persons from 80 years old and older entitled to a monthly Allowance for the Survivor;

c) Retired public servants in communes, wards and towns entitled to monthly social insurance benefits;

d) Persons on unemployment benefits;

dd) Rubber workers on monthly allowances under the Decision No. 206/CP dated May 30, 1979 enacted by the Cabinet Council (now the Government) about policies on old and weak people who undertook hard and harmful works in rubber plantations right after the Revolution Day (1975) .

3. Participants totally paid for by the State, including:

a) Military officers, soldiers, servicemen, non-commissioned officers on active duty; Professional and technical military officers, non-commissioned officers currently working for the people’s public security force; officer cadets, non-commissioned officers, enlisted members working for a pre-determined period in the people’s public security force;

b) Public servants in communes, wards and towns entitled to monthly social insurance benefits from the State budget;

c) Retired persons on monthly benefits from the State budget;

d) Contributors to the Revolution, veterans, including:

- Persons who contributed to the Revolution as defined in the Ordinance on Incentives for contributors to the Revolution;

- Veterans who joined the war of resistance from 1974 and earlier as defined in Clause 6, Article 5 of the governmental Decree No. 150/2006/NĐ-CP dated December 12, 2006 detailing and guiding the implementation of a number of articles of the Veteran Ordinance;

- Persons who joined the war of resistance against the American as defined in the Prime Minister’s Decision No. 290/2005/QĐ-TTg dated November 08, 2005 about policies on a number of subjects who joined the war of resistance against the American but yet to be entitled to the preferential policies offered by the Communist Party and State, and the Prime Minister’s Decision No. 188/2007/ QĐ-TTg dated December 06, 2007 amending and supplementing the Decision No. 290/2005/QĐ-TTg;

- Retired officers, enlisted members as defined in the Prime Minister’s Decision No. 53/2010/QĐ-TTg dated August 20, 2010 about policies on retired officers and enlisted members who joined the war of resistance against the American and had nearly 20 years of experience working for the People’s public security force;

- Discharged servicemen as defined in the Prime Minister’s Decision No. 142/2008/QĐ-TTg dated October 27, 2008 about policies on discharged servicemen who joined the war of resistance against the American and had nearly 20 years of experience in military, and the Prime Minister’s Decision No. 38/2010/QĐ-TTg dated May 06, 2010 amending and supplementing the Decision 142/2008/QĐ-TTg;

- Discharged servicemen as defined in the Prime Minister’s Decision No.62/2011/QĐ-TTg dated November 09, 2011 about policies on discharged, retired servicemen who joined the war of Fatherland protection, did international duties in Cambodia and Laos after April 30, 1975;

- Youth pioneers as defined in the Prime Minister’s Decision No. 170/2008/QĐ-TTg dated December 18, 2008 about policies of health insurance and funeral benefits on youth pioneers who served in the war of resistance against the French and the Decision No. 40/2011/QĐ-TTg dated July 27, 2011 about policies on youth pioneers who fulfilled duties in the war of resistance;

dd) Incumbent members of the National Assembly, members of People’s Councils at all levels;

e) Children under 6 years old (all children residing in the administrative division including children as relatives of those as defined in Point a of this Clause regardless of permanent residence);

g) Persons entitled to monthly social insurance benefits as defined in the Prime Minister’s Decision No. 136/2013/NĐ-CP dated October 21 about policies of social insurance benefits, the Decree No. 06/2011/NĐ-CP dated January 14, 2011 detailing and guiding the implementation of a number of articles of the Law on old age people and the Decree No. 28/2012/NĐ-CP dated April 10, 2012 detailing and guiding the implementation of a number of articles of the Law on the disabled;

h) Persons from poor households, ethnics currently residing in the areas facing extreme socio-economic difficulties; persons residing in island districts and communes according to the Government’s Resolution, the Prime Minister’s Decision and Minister, and Decision by Chairman/Chairwoman of the Committee for Ethnic Affairs;

i) Relatives of the contributors to the Revolution as fathers, mothers, spouses; children of the revolutionary martyrs; caretakers to martyrs;

k) Relatives of the contributors to the Revolution other than those as defined in Point i of this Clause, including:

- Fathers, mothers, spouses, children from 6 - 18 years old, or from 18 years old and older (in case they still attend school or are seriously disabled) of the following subjects: persons taking part in revolutionary movement before January 01, 1945, from January 01, 1945 to the August Revolution Day in 1945;  Heroes of the People’s Armed Forces, heroes of labor in the time of war of resistance; war invalids, soldiers losing from 61 per cent and over of capacity for work; partisans losing from 61 per cent and over of capacity for work as the consequence of chemical agents;

- Children aged from 6 and over of partisans who become disfigured or malformed and unable to perform daily activities as the consequence of chemical agents.

l) Relatives of those as defined in Point a, Clause 3 of this Article (except biological offspring, adopted children under 6 years old);

m) Persons donating their body organs after death;

n) Expatriates who are granted scholarship from the State budget for studying in Vietnam;

o) Caretakers to the contributors to the Revolution, including:

- Caretakers to Vietnamese heroic mothers living in the same family;

- Caretakers to war invalids, wounded soldiers living in the same family;

- Caretakers to partisans living in the same family who lose from 81 per cent and over of capacity for work as the consequence of chemical agents.

4. Participants partly paid for by the State, including:

a) Members of nearly poor households;

b) Students learning at educational institutions that belong to national education system;

c) Members of households relying on agricultural, forestry, fish farming and salt production with average standards of living.

5. Participants as household members, including:

a) All members listed in family register other than the subjects as defined in Clauses 1, 2, 3 and 4 of this Article and members declared as temporary absence;

b) All members listed in temporary residency register other than the subjects as defined in Clause 1, 2, 3 and 4 of this Article;

Example 1: Family B has five household members of which one member is retired on a pension, one member is a public servant and one member registered for temporary residency. Hence, the number of participants in health insurance is four (04).

Article 2. Payment of health insurance premiums (hereinafter referred to as premiums) for a number of participants

1. For any person who is entitled to pension, compensation for loss of capacity for work, social insurance benefits as defined in Clause 2 and Point c, Clause 3, Article 1 hereof, on a monthly basis, the social insurance organization shall pay premiums for these participants from the state budget intended for pension, social insurance benefits.

2. For any contributor to the Revolution as defined in Point d, relative of contributors to the Revolution as defined in Points i and k, caretakers to contributors to the Revolution as defined in Point o, and person enjoying monthly social insurance benefits as defined in Point g, Clause 3, Article 1 hereof:

a) On a quarterly basis, the social insurance organization shall collect and classify the number of issued health insurance cards and the sum of premiums paid for these subjects (See the forms in the Appendix 01) and make submission to the agency of Labor, Invalids and Social Affairs at the same level for transfer to the healthcare fund the respective expenditure from the source used as incentives for contributors to the Revolution and the source for social welfare;

b) Annually, up to December 31 at the latest, the social insurance organization shall preside over and collaborate with the agency of Labor, Invalids and Social Affairs at the same level on completing the payment and transfer of the expenditure of such year to the healthcare fund.

3. For the cases as defined in Points b, d (except contributors to the Revolution), Points e, h and m, Clause 3, Article 1 hereof and members of nearly poor households as defined in Point a, Clause 4, Article 1 hereof that are supported 100 per cent of by State budget as defined in Points a and b, Clause 1, Article of the Decree No. 105/2014/NĐ-CP:

On a quarterly basis, the social insurance organization shall collect and classify the number of issued health insurance cards and the sum of health insurance premiums paid, supported (See the forms in the Appendix 02) and make submission to the agency of Finance for transfer of the expenditure to the healthcare fund as stipulated by Clause 7 of this Article;

4. For members of nearly poor households as defined in Point a, Clause 4 (excepts those supported 100 per cent of the health insurance payment) and members of households relying on agricultural, forestry, fish farming and salt production with average standards of living as defined in Point c, Clause 4, Article 1 hereof:

a) On a three-month, six-month or annual basis, members of households shall pay premiums on their part to the social insurance organization or to the health insurance agencies situated at communes;

b) On a three-month, six-month or annual basis, the social insurance organization shall collect and classify the number of issued health insurance cards, the amount paid by these subjects and the amount supported by the State (See the forms in the Appendix 02) and make submission to the agency of Finance for transfer of the expenditure to the healthcare fund as stipulated by Clause 7 of this Article;

5. For students who are learning at the educational institutions affiliated to national education system as defined in Point b, Clause 4, Article 1 hereof:

a) On a six-month or annual basis, the educational institution shall collect part of the premium rate paid by individual students and transfer such amount to the healthcare fund;

b) Part of the premium rate supported by the State shall be handled as follows:

- For students, the rate of premium supported by the State shall be transferred from the budget of the locality where their educational institution is situated regardless of family register of such students. On a six-month basis, the social insurance organization shall collect and classify the number of issued health insurance cards, the premiums and the amount supported (See the forms in the Appendix 02) by the State to make submission to the agency of Finance for transfer of the expenditure to the healthcare fund as stipulated in Clause 7 of this Article;

- For students who are learning at the educational institution managed by the Ministry and central body, the supported amount shall be paid by the State budget. On a six-month basis, the social insurance organization shall collect and classify the number of issued health insurance cards, the premiums and the amount supported (See the forms in the Appendix 02) to make submission to the Vietnam Social Security for finalization and submission to the Ministry of Finance for the transfer of the expenditure to the healthcare fund;

c) For students of other categories as defined in Clause 3 and Point a, Clause 4, Article 1 hereof who are learning at the educational institution managed by the Ministry and the central body, participation in health insurance shall abide by the provisions as set out in Clause 8 of this Article and the health insurance card should be presented to the educational institution for the establishment of the list of participants and avoidance of coincident issuance of health insurance cards.

6. For participants as household members as defined in Clause 5, Article 1 hereof, on a three-month, six-month or annual basis, members of households shall pay premiums to the social insurance organization or to the health insurance agencies situated at communes;

7. Based on the regulations on decentralized management of local budget, the list of categories of participants, the expenditures paid or supported by the State budget, sent by the health insurance organization, the agency of Finance shall be responsible for transferring such expenditure to the healthcare fund every three months; Annually, up to December 31 at the latest, the transfer of the expenditure of that year to the healthcare fund must be completed.

8. In case one participant of multiple categories as defined in Article 1 hereof, the first category of participants in the order of categories as defined in Article 1 hereof shall be applied.

Article 3. Determination of premiums, supported amount toward a number of participants upon revision of amount of premiums, base pay by the State

1. For category of participants as defined in Clause 3, Article 1 hereof and participants as members of nearly poor households as defined in Point a, Clause 4, Article 1 hereof, the State shall support 100% of the premiums:

The amount supported by the State shall be based on the rate of premiums, base pay in proportion to the time limit stated on the health insurance card.  When the State revises level of premium, base pay, the amount supported by the State shall be revised since new rate of premiums and base pay take effect.

2. For category of participants supported part of the premium rate by the State as defined in Clause 4, Article 1 hereof:

Payment of premiums shall be done on a three-month, six-month or annual basis. The premium paid by the participant and the State shall be based on rate of premium and base pay at the date of payment. When the State revises rate of premium and base pay, both the participant and the State shall not pay the difference as the result of revision of premium and base pay for the rest of the term.

Example 2: Mr. A as a member of nearly poor household who is participating in health insurance for 2015. In January 2015, rate of premium is 4.5% and base pay is VND 1,150,000; supposing that from May 2015, the base pay is revised to VND 1,200,000 – , then the amount paid by Mr. M and supported by the State are determined as follows:

- If the payment of premium is made on a six-month basis (in January and July), the premium paid for the first six months shall be based on 4.5% of VND 1,150,000/month as base pay (Mr. M and the State shall not pay the difference from the revision of base pay in May and June) and the premium paid for the remaining six months shall be based on 4.5% of VND 1,200,000/month as base pay.

- If the payment is made in January on an annual basis, the premium shall be based on 4.5% of VND 1,150,000/month as base pay (Mr. M and the State shall not pay the difference from the revision of base pay from May-December, 2015).

3. Participants as household members as defined in Clause 5, Article 1 hereof:

If payment of premium is done on a three-month, six-month or annual basis, the premium shall be paid according to descending rate from the second member and onward as defined in Point g, Clause 1, Article 2 of the Decree No.105/2014/NĐ-CP and base pay at the date of payment. When the State revises rate of premium and base pay, the participant shall not pay the difference from the revision of premium and base pay for the rest of the term.

Example 3: If four (04) members of Mr.B's family as mentioned in Example 1 of Clause 5, Article 1 hereof want to pay premiums once a year, the premium shall be determined as follows (in case base pay is revised by the State, apply Example 2, Clause 2 of this Article):

- The first member: VND 1,150,000 x 4.5% x 12 months = VND 621,000.

- The second member: VND 621,000 x 70% = VND 434,700.

- The third member: VND 621,000 x 60% = VND 372,600.

- The fourth member: VND 621,000 x 50% = VND 310,500.

Chapter II

LISTING PARTICIPANTS FOR ISSUANCE OF HEALTH INSURANCE CARDS 

Article 4. Responsibilities for making a list of participants 

1. Employers shall be responsible for making a list of participants as defined in Clause 1, Article 1 hereof and make submission to the social insurance organization.

2. People’s Committees of communes shall make a list of participants as defined in Clauses 2, 3, 4 and 5, Article 1 hereof by household, excluding the participants as defined in Point a, Clause 4 and Point n, Clause 3, Point b, Clause 4, Article 1 hereof and make submission to the social insurance organization at district-level, particularly as follows:

a) In 2015, People’s Committees of communes shall make a list of participants and send it to the social insurance organization at district-level on October 01, 2015 at the latest;

b) On a monthly basis, from 2016 and later, People’s Committees of communes shall revise the list of participants and send it to the social insurance organization at district-level for issuance of health issuance cards respectively;

3. Institutions of education and training, vocational training institutions shall be responsible for making a list of participants managed by the Ministry of Education and Training, the Ministry of Labor, Invalids and Social Affairs as defined in Points n and o, Clause 3, Point b, Clause 4, Article hereof and making submission to the social insurance organization no later than October 31 annually.

4. The social insurance organization that receives the list of participants as defined in Clauses 2, 3 of this Article shall be responsible for presiding over and collaborating with agencies, organizations directly in charge of participants on double-checks before issuance of health insurance cards.

5. Making a list of participants managed by the Ministry of National Defense and the Ministry of Public Security as defined in Point a, Clause 1, Article 1; Points a, l (except children under six) and Point n, Clause 3, Article 1; Point b, Clause 4, Article 1 hereof shall be done according to separate regulation.

Example 4: A child named Q, under 6, is an offspring of the military officer as defined in Point 3, Clause 3, Article 1 hereof According to the provisions as set out in Point b, Clause 1, Article 17 amending, supplementing the Law on Health Insurance, the child is entitled to the health insurance card and People’s Committee of the commune where the child resides is responsible for making the list and sending it to the social insurance organization for issuance of health insurance cards.

6. List of participants shall be established according to the forms issued by the social insurance organization.

Article 5. Health insurance cards

1. Specimen health insurance card shall be issued by Vietnam Social Security after approved by the Ministry of Health. The health insurance card shall contain the following information:

a) Code: the code must be in conformity with the personal identification number granted by regulatory agencies. In case the personal identification number is not yet granted, the Vietnam Social Security shall define codes to the participant ensuring that every participant shall have a unique code.

b) Code of insurance coverage rate granted to participants as stipulated in Article 22 amending, supplementing the Law on Health Insurance and Article 4 of the Decree No. 105/2014/NĐ-CP;

b) The term of validity written on the health insurance card (hereinafter referred to as the term of validity) is defined according to the provisions set out in Clause 3, Article 16 amending and supplementing the Law on Health Insurance as follows:

- For persons entitled to unemployment benefits, the term of validity shall correspond to the term of unemployment benefits written on the unemployment benefits eligibility decision issued by competent agencies;

- For children under six years old, the term of validity shall start from the date of birth to 72 months old. In case the child reaches 72 months old before the school year starts, the term of validity shall be extended to September 30 of the year;

- For ethnics residing in the areas facing extreme socio-economic difficulties, persons residing in island districts and communes, the term of validity shall start from January 01 to December 31 of the same year, or to December 31 of the last year as noted on the health insurance card (in case of the term of validity is multi-year long);

- For participants as members of poor households or nearly poor households who are entitled to 100% of the premium rate provided by the State, the term of validity shall start from January 01 to December 31 of the same year: In case the social insurance organization receives the list of participants as members of poor households or nearly poor households enclosed with the written approval of such participants issued by competent agencies after January 01, the term of validity shall start from the date this approval takes effect;

- For participants as members of nearly poor households who are supported part of the premium rate by the State and participants as members of households who rely on agricultural, forestry, fish farming and salt production with average standard of living, the term of validity shall correspond to the term of entitlement to preferential policy as approved by competent agencies for the aforesaid participants; in case this is the first participation, the term of validity shall start after 30 days since the date of payment of premiums;

- For participants as students, the term of validity shall start from January 01 to December 31 of the same year; for participants as first graders and first-year students, the term of validity start from the day of entering school or the expiration date of the previous health insurance card to December 31 of the following year; for participants as 12^th graders and final-year students, the term of validity shall start January 01 to the end of the school year's final month;

- For other categories of participants, the term of validity shall be stipulated by the Vietnam Social Security.

d) As of January 01, 2016, the health insurance card should contain previous continuous period of participation in health insurance by month, at most 60 months, except the cases as defined in Points a, d, e, g, h and i, Clause 3, Article 1 hereof. Continuous period of participation in health insurance means the term of validity of the following card follows closely the expiration date of the previous card; interruption (if any) should not exceed three months;

For participants as employees appointed for studying or working overseas, the continuous period of participation in health insurance means the period from the time of studying or working overseas until a recall is issued by their organization or agency;

For participants as overseas workers, within a period of 60 days since the date of entering the country (Vietnam), if participating in health insurance, the continuous period of participation in health insurance includes the entire period of working overseas up to the date of participating in health insurance;

For participants as employees who are in the process of filing procedures for entitlements to unemployment benefits as stipulated by the Law on Employment, the continuous period of participation in health insurance includes the period for preparing the procedures for entitlements to unemployment benefits according to the Law on Employment in Vietnam.

Example 5: Mr. M has a continuous period of participation in health insurance from December 21, 2013 to December 31, 2015; the continuous period of participation to be written on the health insurance card with the term of validity starting from January 01, 2016 shall be “The continuous period of participation in health insurance up to December 31, 2015: 24 months and 10 days”.

Example 6: Mr. V’s continuous period of participation in health insurance up to December 31, 2015 is 70 months; the continuous period of participation to be written on the health insurance card with the term of validity starting from January 01, 2016 shall be “The continuous period of participation in health insurance up to December 31, 2015: over 60 months”.

Example 7: Ms. K is working in an enterprise and participating in health insurance continuously from January 01, 2013 to January 05, 2015 when her employment contract is terminated. On April 04, 2015, Ms. K submitted the documents to apply for entitlements to unemployment benefits (within three months). On April 20, 2015, the competent agency issued the unemployment benefits entitlement decision (within 20 days). On April 26, 2015, the social insurance organization received the decision and carried out the payment of unemployment benefits to her as of May 01, 2015 (for a term of three months). In this case, the continuous period of participation in health insurance up to April 30, 2015 is 28 months.

2. Issuance of health insurance cards to persons who donate body organs according to the law shall be done as follows:

a) The medical establishment where body organs are taken shall be responsible for noting “body organs have been donated" on the hospital discharge papers;

b) Based on such hospital discharge papers as defined in Point a of this Article, the social insurance organization shall issue the health insurance card to the donor and make a written notice to People’s Committees of communes where such donor resides;

c) The term of validity shall start from the date the donor is discharged from hospital.

Chapter III

FACILITIES THAT PROVIDE MEDICAL SERVICES TO POLICYHOLDERS OF HEALTH INSURANCE (Hereinafter referred to as healthcare providers)

Article 6. Healthcare providers, registration for medical services covered by health insurance and hospital transfer 

1. According to the Law on Medical Examination and Treatment, healthcare providers shall execute a contract for provision of medical services to policyholders (hereinafter referred to as the contract for medical services) with the social insurance organization.

2. Registration for medical services at primary healthcare providers, and hospital transfer shall be done according to the regulations by the Ministry of Health.

Article 7. Contract for medical services covered by health insurance 

1. General principles:

a) The social insurance organization shall be responsible for contracting with medical facilities. The contract for medical services shall be drafted according to the provisions set out in the Appendix 03 enclosed herewith. Depending on conditions of the medical facility, the social insurance organization and the medical facility shall be unanimous in supplementing some terms and conditions to the contract without going against the Law on Health Insurance;

b) The term of validity of the contract shall conform to the fiscal year, starting from January 01 to December 31 of the same year; for any contract what is made for the first time, the term of validity of the contract shall start from the day of signing to December 31 of the same year;

c) Expense for medical services provided to insured patients before January 01 but discharged since January 01, shall be set as follows:

- In case the healthcare provider continues to sign a contract for medical services, the expenses shall be transferred to the succeeding year;

- In case the healthcare provider discontinues signing a contract for medical services, the expenses shall be included in the preceding year;

2. Documents for entering into the contract for medical services:

a) With respect to any healthcare provider that signs a contract for the first time:

- Healthcare provider’s official offer for signing the contract;

- Healthcare provider’s operation license;

- Hospital classification decision issued by competent agencies (if any); with respect to non-public healthcare providers, it is required to have the decision on professional and technical healthcare network issued by competent agencies.

b) With respect to any healthcare provider that signs a one-year contract annually:

Supplement functions, duties, scope of profession, hospital level approved by competent agencies (if any).

3. Procedures for entering into the contract for medical services:

a) With respect to any healthcare provider that signs the contract for the first time:

- The healthcare provider must submit a dossier as regulated in Point a, Clause 2 of this Article to the social insurance organization decentralized by the Vietnam Social Security;

- Within 30 days since the receipt of adequate documentation, the social insurance organization must complete the examination of the documentation and signing the contract; in case of refusal, the social insurance organization must make a written notice and state the reasons.

b) With respect to any healthcare provider that signs a one-year contract annually: Both the healthcare provider and the social insurance organization must complete the signing of the contract for the succeeding year before December 31.

4. The contract for medical services signed with commune-level healthcare provider and medical facilities that belong to agencies, organizations and schools:

a) Commune-level healthcare providers:

- The social insurance organization shall sign a contract with the district-level hospital or medical center where the district-level hospital is not yet separated, or other primary healthcare providers approved by the Services of Health for providing medical services at the commune-level medical facility:

- Within the assigned fund, the district-level hospital or the medical center at district level, or other healthcare providers as approved by the Services of Health shall be responsible for providing medicine, chemicals, medical materials, hospital beds (if any), medical technical services to the commune-level medical facility within its own scope of specialty, and at the same time carrying out surveillance and finalizing payment with the social insurance organization.

- Total expenditure for medical services provided at the commune-level medical facility must range between 10 per cent and 20 per cent of the fund for medical services to outpatients calculated on the number of individuals registering with primary healthcare providers at commune-level as defined in Point a, Clause 4, Article 11 hereof.

- The time for retaining patients for treatment at the commune-level medical facility should not exceed 03 days, or 05 days with respect to any commune-level medical facility in the area facing socio-economic difficulties, or in island districts, communes.

b) For medical facilities that belong to agencies, organizations and schools (except agencies, organizations and schools that are granted expenditure for initial medical services as defined in Points b, c, Clause 1, Article 6 of the Decree No. 105/2014/NĐ-CP):

Agencies, organizations and schools managing the medical facility that contracts with the social insurance organization shall be responsible for providing medicine, chemicals, medical materials, technical medical services to meet demand for medical services. In case agencies, organizations and schools managing the medical facility at the same level as commune-level medical facility fail to provide medicine, chemicals, medical materials, technical medical services to meet demand for medical services, the social insurance organization shall contract with the district-level hospital or medical center.

5. For general clinics affiliated to the district-level hospital or medical center, apply the same as every ward of the district-level hospital or medical center. Based on the stipulations on specialty and pricelist of medical services as approved by competent agencies, the social insurance organization and the district-level hospital or medical center shall be unanimous in the contract for medical services provided at the general clinics.

Article 8. Procedures for access to medical services covered by health insurance 

1. Participants that go for medical examination and treatment must present a health insurance card with photo; in case the health insurance card has no photo, some papers proving identity of such person must be presented.

2. Children under six who go for medical examination and treatment shall present health insurance cards only. Presentation of notice of birth or birth certificate is required in case the participant receives medical services without health insurance cards; in case the treatment to the participant takes place right after birth without notice of birth, head of the medical facility, parents or guardian to the child shall confirm the medical records as foundation for payment as stipulated in Clause 2, Article 13 hereof and shall be responsible for such confirmation.

3. Participants that go for medical examination and treatment must present an appointment note or some papers proving identity of such person while pending replacement of the health insurance card by the social insurance organization.

4. Participants as body organ donors going for medical examination and treatment must present some papers as defined in either Clause 1, Clause 2, or Clause 3 of this Article. In case the donor is brought for medical treatment right after donation without health insurance card, the donor still enjoys the benefits as a policyholder; Head of the medical facility where body organs are taken, the donor or his/her relatives must confirm the medical records as foundation for payment as stipulated in Clause 3, Article 13 hereof and be responsible for such confirmation.

5. In case of transfer for medical facilities, participants must present some papers as defined in either Clause 1, Clause 2, or Clause 3 of this Article and transfer papers as stipulated by the Ministry of Health.

6. In case of emergency, participants shall be entitled to go to any medical facility provided that such papers as defined in either Clause 1, Clause 2, or Clause 3 of this Article must be presented before being discharged. After the stage of emergency, the participant shall be transferred to other wards or medical treatment rooms for further surveillance, treatment or transfer to other medical facilities as required.

When a patient is discharged from hospital, any medical facility that does not contract with the social insurance organization must provide to the patient the documents related to pathological state and other vouchers for medical services as foundation for payment with the social insurance organization as stipulated in Articles 14, 15 and 16 hereof.

7. Participants on a follow-up visit to medical facilities at upper level without going to primary healthcare providers must present papers as defined in Clause 1, Clause 2, or Clause 3 of this Article enclosed with a medical appointment note. Every medical appointment note shall become ineffective once used. Based on the patient's conditions and technical requirements, the doctor shall decide a follow-up visit for the patient.

8. Participants going for medical examination and treatment (not in the case of emergency) while on a business trip, doing ambulatory job; attending the concentrated training course shall be granted health insurance covered by primary healthcare providers at the same professional and technical level as or similar to the medical facility noted on the health insurance card and must present such papers as defined in either Clause 1, Clause 2 or Clause 3 of this Article, together with one of the following documents: work order, decision on appointment for study, and other papers registering for temporary residence.

9. Medical facilities and the social insurance organization are not permitted to prescribe additional administrative procedures in provision of medical services besides the procedures set out in this Article. In case the medical facility and the social insurance organization need to copy the health insurance card, hospital transfer note and other papers concerning medical services for their own management, they must do it by themselves and should not ask patients to pay for this.

Article 9. Health insurance appraisal

1. The social insurance organization shall carry out the appraisal of health insurance and be responsible for results of appraisal according to the provisions set out in the Law on Health Insurance.

2. Content of health insurance appraisal comprises:

a) Examine procedures for medical services provided to policyholders according to the provisions set out in Article 8 hereof;

b) Examine and assess treatment, use of medicine, chemicals, medical materials and technical medical services within the scope of policyholders’ entitlement to benefits and number of days of hospital stay.

c) Examine, assess and determine expenses for medical services:

- Preparation of a payment bill to patients and a list of expenses for medical services to inpatients, outpatients must be in conformity with the expenses and forms as regulated;

- Examine expenses requested for payment by medical facilities.

d) Collaborate with health workers at the medical facility on handling difficulties in procedures for medical services, rights and responsibilities of policyholders; explain and disseminate policies on health insurance to patients at wards and medical treatment rooms.

3. Appraisal of health insurance shall be done concurrently or after the patient is discharged from hospital and must ensure accuracy, transparence and openness. Results of appraisal shall be made in writing and notified to the medical facility.

4. Content of health insurance appraisal must ensure unanimous agreement between medical facilities and the social insurance organization. In case it is not unanimously agreed, opinions or comments from both sides must be clearly stated and notified to agencies at upper level for handling.

5. The Vietnam Social Security shall provide specific guidance on the content and procedures for health insurance upon receipt of approval from the Ministry of Health.

Chapter IV

PAYMENT ON MEDICAL SERVICES BETWEEN SOCIAL INSURANCE ORGANIZATION AND MEDICAL FACILITIES

Article 10. Capitation payment method

1. General principles:

a) Capitation payments mean defined, periodic, per-patient payments within the scope of service for each individual enrolled in a medical facility (hereinafter referred to as capitation fees);

b) Total capitation fund for payment is the amount calculated on the number of health insurance cards registered and determined capitation fees);

c) The medical facility shall use the source of expenditure determined in a year to provide medical services to policyholders and shall not charge anything extra within the scope of entitlement for policyholders. The social insurance organization shall be responsible for overseeing and ensuring benefits of policyholders.

2. Determination of capitation fund:

a) Annual capitation fund assigned to the medical facility is determined by multiplying capitation fee by total number of health insurance cards in the year and shall be adjusted according to coefficient k as stipulated in Point d of this Clause;

b) Capitation fee is determined according to professional and technical healthcare network by having total expenses for medial services in the preceding year divided by total number of individuals registering with primary healthcare providers at the same professional and technical healthcare network;

b) Total expenses for medical services by professional and technical healthcare network in the preceding year are expenses for medical services provided to individuals by the primary healthcare providers of the same network, including: expenses for medical services provided at medical facilities of the same network (inside and outside of province), and other medical facilities other than the primary healthcare provider’ location except the expenses as defined in Point dd of this Clause;

d) Coefficient k is the adjustment coefficient for medical service expenses and other related factors in the succeeding year versus the preceding year. Coefficient k applied in 2015 is 1,10, and from 2016 and later shall be adjusted according to the indicator of medicine category and medical service of the preceding year announced by General Statistics Office;

dd) Expenses for transportation, hemodialysis, human organ transplantation, cardiac surgery, cardiovascular intervention, treatment for cancer, hemophilia and expenses shared by the patient shall not be included in the capitation fund;

e) The capitation fund assigned to the healthcare provider shall not exceed the fund for provision of medical services by this provider as defined in Point a, or Point b, Clause 4, Article 11 hereof subtracting expenses for non-capitated medical services arising in the year. In special case, the social insurance organization at province-level shall make a report to the Vietnam Social Security for consideration and revision but such capitation fee as revised should not exceed overall average expenses according to professional and technical healthcare network across the country determined and announced annually by the Vietnam Social Security.

3. Overseeing and adjustment of capitation fund:

When there is some change in the number of health insurance cards registered at the healthcare provider, the Vietnam Social Security at province-level shall be responsible for notifying the healthcare provider of the number of health insurance cards and total capital fund to be used. In case expenses for medical services have changed due to fluctuations in medical price structure, application of new medical services and medicine, and other related factors, or there is some change in functions and duties of the healthcare provider, the two sides shall be unanimous in re-arranging capitation fees and making adjustment as appropriate.

4. Use of capitation fund:

a) The capitation fund shall be used to pay expenses for medical services provided to policyholders including expenses for medical services provided at healthcare providers at commune-level and other medical providers as defined in Articles 14, 15 and 16 hereof. The social insurance organization shall be responsible for notifying healthcare providers of any expense arising from other healthcare providers and subtracting it from the capitation fund assigned to such a healthcare provider.

b) In case the capitation fund has residuals, the healthcare provider shall include such residuals to the public service provider’s earnings. The residual should not exceed 20% of the capitation fund, the remaining amount shall be transferred to provincial healthcare fund for management and use. If the capitation fund includes expenses for medical services at commune-level medical facilities, a portion of the residual shall be transferred to commune-level medical facilities according to the number of health insurance cards registered at each medical facility.

c) Inadequate capitation fund:

- Due to objective reasons such as increased frequency of hospital visit, application of new technical services, the social insurance organization shall consider and pay at least 60 per cent of the excess of the capitation fund;

- Due to irresistible reasons such as outbreak of epidemic and higher-than-expected rate of patients, the social insurance organization at province-level and the Services of Health shall review and make supplemental payment to the healthcare provider. In case provincial healthcare fund is inadequate for the supplements, report to the Vietnam Social Security for consideration and handling.

5. The healthcare provider shall examine and work out expenses for medical services provided to policyholders who do not register for initial medical examination and treatment at the facility, non-capitated medical services as defined in Point c, Clause 2 of this Article to carry out payment to the social insurance organization.

Article 11. Fee-for-service payment

1. Fee-for-service payment is the payment method that is based on expenses for medicine, chemicals, medical materials and equipment, technical medical services used for patient at the medical facility.

2. Fee-for-service payment shall be applicable in the following cases:

a) Healthcare providers that do not use capitation payment method

b) Insured patients who do not go for medical examination and treatment at their primary healthcare providers;

c) Some illnesses, group of diseases, technical medical services that are not included in the capitation fund of the healthcare provider that applies capitation payment as defined in Point c, Clause 2, Article 10 hereof.

3. Payment: Expenses for technical medical services shall be calculated based on prices for medical services approved by competent agencies; expenses for medicine, chemicals and medical materials shall be calculated according to purchasing price but not exceed tender price; expenses for blood, preparations of blood shall be stipulated by the Ministry of Health.

4. Healthcare fund at primary healthcare providers shall be determined according to the provisions set out in Clause 1, Article 14 hereof, specifically as follows:

a) For any medical facility that provides medical services to inpatients and outpatients:

- 90 per cent for medical services provided at current facility, at other medical facilities and transportation fees (if any);

- The remaining 10% shall be adjusted and supplemented according to the provisions set out in Clause 5 of this Article.

b) For any medical facility that provides medical services to outpatients only:

- 45 per cent for medical services provided to outpatients at current facility, at other medical facilities and transportation fees (if any);

- 5 per cent for adjustments and supplements to the medical facility according to the provisions set out in Clause 5 of this Article.

- The remaining 50 per cent shall be used by the social insurance organization for payment on medical services provided to inpatients;

c) The social insurance organization shall be responsible for paying the expenses for medical services provided to policyholders at other medical facilities and subtracting such expenses from the fund permissible for the healthcare provider as noted on the health insurance cards.

5. In case the expenses for medical services provided exceed total fund permissible for the healthcare provider, the social insurance organization shall make adjustments as follows:

a) Adjust, supplement 10 per cent of the fund with respect to medical facilities providing medical services to inpatients and outpatients;

a) Adjust, supplement 05 per cent of the fund with respect to medical facilities providing medical services to outpatients;

c) In case it is still inadequate, the social insurance organization shall be responsible for making payment and additions within the scope of local fund; if the local fund is inadequate, report should be made to the Vietnam Social Security for consideration and handling.

6. Total expenses for medical services provided (except medical services provided by primary healthcare providers) do not exceed actual average expenses multiplying the number of turns of hospital visits in the year and by the coefficient k. The actual average expense means the expense for medical services (within the limit of benefit) provided to a wave of inpatients and a turn of outpatients of the preceding year)

Annually, based on the price of medicine and medical services in the preceding year announced by General Statistics Office, the social insurance organization shall announce and adjust total payment made to medical facilities;

In case expenses arise out of change in prices for medical services, application of new medical services and other related factors, or out of change in functions, duties of the medical service provider as decided by competent agencies, the social insurance organization shall pay such expenses and include them to the total expenses in the year as foundation for determination of average expenses in the succeeding year.

In case the medical facility’s spending exceeds total permissible fund, such difference shall not be covered by the healthcare fund.

Article 12. Per-visit payment

1. Per-visit payment is a full payment based on the expenses for medical services predetermined for each diagnosis.

2. Foundations for classifying and determining each diagnosis shall conform to the regulations of the Ministry of Health.

3. Per-visit lump sum shall be based on applicable regulations on prices of medical services.

4. The Ministry of Health shall provide guidance on pilot payment for each case.

Article 13. Payment for health insurance 

1. Payment for transportation of patients from commune-level healthcare network to upper-level one in case of emergency with respect to the cases as defined in Point d, e, g, h and i, Clause 3, Article hereof , or in case of inpatient treatment, the transfer for treatment shall be done as follows:

a) In case patients use transportation provided by the healthcare provider, the healthcare fund shall cover such expenses equivalent to 0.2 liters of petrol for every kilometer of actual traveling distance between the two facilities according to the petrol rate at the time of fill-up.  In case more than one patient are transferred on the same vehicle, the payment applies the same as the case of transfering one patient. The medical facility that receives the patient must give confirmation on the car service order from the transfering facility;

b) In case patients do not use transportation provided by the healthcare provider, the healthcare fund shall cover expenses for one-way transportation that is equivalent to 0.2 liters of petrol for every kilometer of actual traveling distance between the two facilities according to the petrol rate at the time of fill-up.  The medical facility that affects the transfer must be responsible for facilitating this payment to the patient in advance and with the healthcare fund later. 

2. Payment for medical services provided to children under six without presentation of health insurance cards;

a) The medical facility must be responsible for making a list of children under six who have received medical examination and treatment enclosed with a copy of notice of birth or birth certificate; in case the treatment takes place right after birth with a notice of birth being not yet issued, head of the medical facility, parents or guardian to the child shall confirm the medical records as foundation for payment as stipulated in Clause 2, Article 8 hereof.

b) The social insurance organization must be responsible for examining and verifying the issuance of health insurance cards to the children in reliance on the list of children who have received medical examination and treatment and transferred from the medical facility. Any child who is not yet granted the health insurance card still receives medical services and such expense shall be balanced against the medical facility’s permissible fund after the child is issued the health insurance card. In case a child is determined as being issued the health insurance card, such expense is balanced against the child’s primary healthcare provider’s permissible fund.

3. Payment for expenses for medical services provided to organ donors subject to immediate treatment without health insurance card:

a) The medical facility where body organs are taken must be responsible for making a list of organ donors and monthly expenses for medical services provided to individual donors, and then making the submission to the social insurance organization for payment;

b) The social insurance organization shall be responsible for issuing health insurance cards to the donors as regulated by the law and balance such expense against the medical facility’s permissible fund.

4. Payment for medical services with respect to technical medical services conducted by the upper-level medical facility under the healthcare network guidance program, the plans for supporting and enhancing professional capability to lower-level networks as initiated by the Minister of Health:

a) In case the price level of technical medical services is approved by competent agencies, the health insurance shall cover the payment based on such level;

b) In case the price level of technical medical services is not yet approved, the healthcare fund shall cover the payment based on the price level set by the technical transfer facility and approved by competent agencies; Medical facilities receiving technical transfer shall be responsible for notifying the province-level social insurance organization of technical medical services provided under the program and plan initiated by the Minister of Health and making submission to competent agencies for approval the list of technical services and prices of medical services as foundations for the implementation of technical transfer reception and proceeding payment to the social insurance.

5. In case the medical facility gets overloaded and must provide medical examination and treatment on weekends, holidays, that medical facility must make a written notice to the social insurance organization for supplements to the contract for medical services before implementation.  Insured patients going for medical examination and treatment shall be covered by the healthcare fund within the limit of benefits. The medical facility shall be responsible for ensuring adequacy of staff and professional conditions and must make public all the expenses arising outside the limit of benefits and make a prior notice to the patients about such expenses that shall be paid by the patients themselves.

Chapter V

PAYMENT ON MEDICAL SERVICES MADE BETWEEN THE SOCIAL INSURANCE ORGANIZATION AND PATICIPANTS;

Article 14. Payment on medical services

Payment on medical services made according to the provisions set out in Clause 2, Article 31 on amendments and supplements to the Law on Health Insurance shall comprise:

1. Medical services provided by a non-contracting medical facility

2. Medical services provided outside the procedures for medical examination and treatment as regulated by Article 8 hereof.

Article 15. Documentation for payment request

1. Payment request form for medical services shall be made according to the form issued by the Vietnam Social Security.

2. Procedures and papers as regulated in Article 8 hereof.

3. Hospital discharge note

4. Originals of proper documents (invoices of medicine and hospital fees and related vouchers).

Article 16. Direct payment

1. Insured patients or their relatives must be responsible for making submission of the documentation to the district-level social insurance organization where they reside as regulated in Article 15 hereof.

2. The district-level social insurance organization must be responsible for:

a) Receiving the documentation submitted by the insured patients or their relatives and make a receipt. Any documentation found inadequate must be supplemented;

b) Completing appraisal of health insurance and making payment on medical services direct to the insured  patients within a period of 40 days since receipt of adequate documentation. Making a written notice included with reasons to the patients in case the payment is not facilitated;

c) Totaling all the expenses paid to insured patients and balancing such expenses against the patient’s primary healthcare provider’s permissible fund.

3. Health insurance payment limit:

a) In case insured patients going for medical examination and treatment provided by a contracting medical facility, the payment shall be made within the limit of benefits.

a) In case insured patients going for medical examination and treatment provided by a non-contracting medical facility, the payment shall be made on actual expenses within the limit of benefits but not in excess of the limit as regulated in the Appendix 04 enclosed hereof.

Chapter VI

MANAGEMENT AND USE OF HEALTHCARE FUND

Article 17. Use of the healthcare fund according to the provisions set out in Clause 1, Article 6 of the Decree No. 105/2014/NĐ-CP

1. Allocation of healthcare fund to primary healthcare providers:

Based on the overall healthcare fund at province-level determined according to the provisions set out in Clause 1, Article  6 of the Decree No. 105/2014/ NĐ-CP, the social insurance organization at province-level shall be responsible for allocating healthcare fund to primary healthcare providers. The formula for calculation is below:

where

- Total health insurance revenues are determined according to the provisions set out in Clause 1, Article 6 of the Decree No. 105/2014/CĐ-CP (equal to 90 per cent of the health insurance premiums on a provincial scale).

- Total expenses paid on medical services provided by primary healthcare providers on a provincial scale are determined according to the provisions set out in Clause 2  of this Article.

2. Transfer expenditure to educational institutions that belong to the national education system, agencies, organizations and enterprises that qualify for providing medical services as primary healthcare providers as prescribed in Article 18 hereof:

a) Preschool education institution:

- A portion reserved for preschool education institution comprise two amounts: 5 per cent of total health insurance revenues calculated over the total number of children under six at the institution and 1 per cent of total health insurance premiums paid by the institution to the social insurance organization as stipulated in Point c of this Clause.

In the first month of the school year or academic course, the social insurance organization shall be responsible for transfering the abovementioned amount of money to preschool education institution.

Example 8: Preschool education institution B qualifies for providing medical services as a primary healthcare provider to 100 learners under six years old in 2015. Supposing that the premium rate equals 4.5 per cent of VND 1,150,000 as a base pay, the amount of money transferred to the institution is VND 3,105,000:

5% x (100 children x 4.5% x VND 1,150,000/month x 12 months)

Additionally, the social insurance organization must reserve for the pre-school educational institution a portion equal to 1 per cent of the total health insurance premiums paid by the institution to the social insurance organization as shown in Example 10 in Point C of this Clause.

a) Other educational institutions:

- A portion reserved for other educational institutions comprise two amounts: 7 per cent of total health insurance revenues calculated over the total number of students as policyholders (including students as participants entitled to other categories of health insurance) and 1 per cent of total health insurance premiums paid by the institution to the social insurance organization as stipulated in Point c of this Clause.

- In the first month of the school year or academic course, the social insurance organization shall be responsible for transfering the abovementioned amount of money to the educational institution.

Example 9: University K qualifies for providing medical services as a primary healthcare provider to its students. In 2015-2016 school year, there are 5,000 students attending in this university of which 100 students are from poor households, 100 students are relatives of military forces, 100 students relatives of the contributors to the Revolution and 4,700 students are of other health insurance participants> Supposing that the premium rate for all participants equals 4.5 per cent of VND 1,150,000 as a base pay, the amount of money transferred to the institution is VND 217,350,000:

7% x (5,000 students x 4.5% x VND 1,150,000/month x 12 months)

Additionally, the social insurance organization must reserve for University K a portion equal to 1 per cent of the total health insurance premiums paid by the institution to the social insurance organization as shown in Example 10 in Point C of this Clause.

c) Agencies, organizations and enterprises:

- A portion that equals 1 per cent of the total health insurance premiums paid by such agencies, organizations and enterprises to the social insurance organization:

- On a monthly basis, after receiving the health insurance premiums from agencies, organizations and enterprises, the social insurance organization shall be responsible for reserving a portion to the agencies, organizations and enterprises.

Example 10: Enterprise A that has its own healthcare provider (without entering into a contract for medical services with any other healthcare providers) pays to the healthcare fund an amount of VND 105 million as health insurance premiums of which VND 100 million is the compulsory amount and VND 5 million is a fine imposed for overdue payment. After receiving this amount, the social insurance organization shall be responsible for reserving a portion equal to VND 1 million for Enterprise A (1% x VND 100,000,000).

Article 18. Payment for the provision of medical services at educational institutions, agencies and enterprises; 

1. Educational institutions, agencies, organizations and enterprises (other than those that have their own healthcare providers) shall be granted expenditure from the healthcare fund for providing primary medical services to persons who belong to such educational institutions, agencies and enterprises when the following conditions are met:

a) There must be at least one person in charge or holding several office positions or on a labor contract for at least three months as a medical technician at a minimum.

b) There must be a medical clinic or a separate room for conducting first-aids or primary medical tasks on persons working for such educational institutions, agencies, organizations and enterprises during their period of learning and working at the educational institution, agency or enterprise...

2. Payment for primary medical services:

a) Expenses for medicine, medical materials serving first-aids and primary medical tasks on children, students, and other persons that belong to such educational institutions, agencies, and enterprises during their period of learning and working at the educational institution, agency or enterprise...;

b) Expenses for repair or purchase of medical equipment, facilities serving the provision of primary medical services at educational institutions, agencies and enterprises;

c) Expenses for purchase of stationery, filing cabinets used to keep medical records of children, students and employees;

d) Expenses for purchase of books, materials and tools serving extracurricular propaganda and education about health care consulting, reproductive health and family planning at educational institutions, agencies and enterprises;

dd) Other expenses for conducting primary medical tasks at educational institutions, agencies and enterprises;

3. Management and settlement of expenditure:

a) Educational institutions, agencies, organizations and enterprises granted such expenditure from the healthcare fund shall be responsible for providing primary medical services to persons who belong to educational institutions, agencies and enterprises other than for other purposes.

b) Expenses for primary medical services as defined in Clause 2 of this Article shall be entered into accounts and settled as follows:

- For public educational institutions, the expenses for primary medical services shall be included to the expenses for medical services provided at the medical facility and final settlement with upper-level agency must be made according to the applicable regulations;

- For non-public educational institutions, the expenses for primary medical services shall be included to the non-public education institution’s expenses and final settlement must be made with upper-level agency (if any);

- For enterprises or economic organizations, accounting books should be opened separately to reflect receipt and use of expenses and not include them to the enterprises or economic organizations’ expenses;

- For other agencies or organizations, the expenses for primary medical services shall be included to the expenses for medical tasks conducted at agencies or organizations and final settlement with upper-level agency (if any) or financial agency must be made according to the applicable regulations;

c) Educational institutions, agencies, organizations and enterprises granted expenditure for conducting primary medical services according to the provisions as set out in this Article shall not be required to make final settlement with the social insurance organization but shall be responsible for reporting to upper-level agencies the use of the expenditure at the request of the social insurance organization or competent agencies.

d) The expenses granted to the end of year shall be transferred to the following year if they are not used up.

Article 19. Expenditure as support to the People’s Committees of communes for making a list of participants in the administrative division

1. Supportive budget paid to the People’s Committees of communes for making a list of participants in the administrative division comes from the Vietnam Social Security’s annual expense estimate for management.

2. Supportive budget paid to the People’s Committees of communes shall be based on the number of participants in the list and level of budget to be paid shall be announced annually by the Vietnam Social Security based on the estimated level approved by the Prime Minister; As for 2015, level of budget to be paid is VND 1,500 for a participant.

3. Payment of supportive budget to the People’s Committees of communes for making a list of participants in the administrative division:

a) As for the year 2015, to the end of March at the latest, the social insurance organization at district-level shall provide an advance equal to 50 per cent of the supportive budget according to the level as defined in Clause 2 of this Article and the entire population of the commune at the time of payment. The remainder shall be transferred upon receipt of the list of participants as stipulated in Point a, Clause 4, Article 4 hereof.

b) As of 2016, the social insurance organization at district-level shall transfer the supportive budget to the People’s Committee of communes after receiving the revised list of participants according to the provisions set out in Point b, Clause 4, Article 4 hereof.

Example 11:

- In 2015: Commune N has a population of 6,000 and the amount advanced to the People's Committee of Commune is VND 4,500,000 (50% x VND 1,500 x 6,000 people). The remainder shall be transferred after the list of participants is received as defined in Point a, Clause 4, Article 4 hereof:

- In 2015: Commune N reports an increase of 30 people and a decrease of 10 people. Supposing that the expense for the formation of the list of participants applied in 2015 is VND 2,000/person; the supportive budget granted to the People’s Committee of Commune is VND 80,000:

(30 people (increase) + 10 people (decrease) x VND 2,000 = VND 80,000

c) The transfer of the supportive budget is done via transfer or in cash.

4. The People’s Committee of the commune that is granted the supportive budget for the formation of the list of participants shall not make any financial settlement with the budget of the commune but shall open a separate accounting book to reflect the use of the budget.

Chapter VII

IMPLEMENTARY PROVISIONS

Article 20. Transitional clause

1. In 2015, the social insurance organization shall issue health insurance cards to policyholders based on the list of participants sent by the agency, organization and enterprise where they (participants) are working. Upon receipt of the list of participants in 2015 sent by the People’s Committee of commune, the social insurance organization shall be responsible for checking and ensuring proper issuance of health insurance cards.

2. For policyholders having traffic accidents:

a) Any case hospitalized before January 01, 2015 and discharged since January 01, 2015, or any case hospitalized since January 01, 2015 shall be entitled to the health insurance benefits within the limit as regulated;

b) Any case hospitalized after a traffic accident due to violation of the Law on Traffic and discharged before 01, 2015 shall be entitled to the health insurance benefits within the limit as regulated.

3. In case the patient is chosen for treatment by applying technical services as stipulated in the Ministry of Health’s Decision No. 36/2005/QĐ-BYT dated October 31, 2005 on promulgation of high-cost technical services, the insured patient shall be entitled to the limit of benefits but not in excess of 40 months of base pay per use of such technical service until the Ministry of Health issues the list of technical services, rate and conditions for payment within the limit of benefits for policyholders (except the cases as defined in Point b, Clause 4, Article 4 of the Decree No. 105/2014/CĐ-CP.

4. With respect to any contract for the provision of medical services signed before the effective date of this Circular, the social insurance organization and healthcare provider must agree to make appropriate amendments and supplements to the provisions set out hereof.

Article 21. Effect

1. This Circular shall take effects since February 01, 2015 and the provisions set out hereof shall be executed as of January 01, 2015.

2. The following documents and regulations shall become invalid since the effective date of this Circular:

a) The Ministry of Health – the Ministry of Finance’s Joint Circular No. 09/2009/TTLT-BYT-BTC dated August 14, 2009 providing guidance on the implementation of health insurance and Joint Circular No. 24/2014/TTLT-BYT-BTC amending and supplementing a number of articles of the Joint Circular 09/2009/TTLT-BTY-BTC;

b) The Ministry of Health – the Ministry of Finance’s Joint Circular No. 39/2011/TTLT-BYT-BTC dated November 11, 2011 providing guidance on payment for medical services provided to traffic-related patients insured:

c) The following provision set out in Clause 2, Section II of the Ministry of Finance’s Circular No. 14/2007/TT-BTC dated March 08, 2007 providing guidance on medical tasks performed in schools "With respect to the expenditures provided by the healthcare fund volunteered by students, the educational institutions shall be responsible for managing, using and making financial settlement with the social insurance organization according to applicable regulations”.

Article 22. Implementation

1. The Vietnam Social Security shall be responsible for:

a) Issuing specimen health insurance card, appointment note for replacement of health insurance card, procedures for issuance, replacement, revocation of health insurance cards after approved by the Ministry of Health;

b) Issuing specimen declaration form for first-time participants and providing guidance to participants on making the declaration for issuance of health insurance cards;

c) Making timely notice to the social insurance organizations at provincial and municipal level for revising expenses for medical services provided to insured patients at medical facilities in reliance on medicine category and medical services of the preceding year announced by the General Statistics Office;

d) Instructing the social insurance organizations at provincial and municipal level to cooperate with the Services of Health, the Services of Finance, medical facilities in the administrative division and relevant agencies in handling difficulties within their competence or sending proposal to competent authorities for handling;

dd) Instructing the social insurance organization of all levels to provide forms, computer softwares (if any) to People’s Committees of communes for the formation and management of the list of participants by household;

e) Instructing the social insurance organizations at provincial and municipal level to determine the cumulative expenses for medical services in the year to issue the certificate of total exemption from payment on medical services to any person who has participated in health insurance for at least five years and has paid a share (valued more than six months of base pay in a year) of the expense paid on medical services with the social insurance organization not taking into account the cases going for medical examination and treatment off the line (not the same healthcare network) as defined in Point c, Clause 2, Article 22 amending and supplementing the Law on Health Insurance.

Example 12: To May 01, 2015, Mr. M’s uninterrupted period of participation in health insurance is 60 months and his share of the expense paid on medical services from January 01, 2015 to May 01, 2015 is VND 7 million (more than six months of his base pay). From May 01, 2015 to the end of December 31, 2015, Mr. A shall enjoy total exemption from payment on medical services provided within the limit of health insurance benefits as stipulated.

2. The Services of Health shall be responsible for:

a) Presiding over and cooperating with the social insurance organizations at provincial level in raising public awareness of the matter and instructing medical facilities to conduct medical examination and treatment on insured patients as stipulated by the Law on Health Insurance and the Law on amendments and supplements to a number of articles of the Law on Health Insurance, Decree No. 105/2014/NĐ-CP and this Circular;

b) Presiding over and cooperating with the Service of Health and the social insurance organizations at provincial level in the neighboring administrative division in organizing the provision of medical services and transfer of professional and technical healthcare network for the benefits of policyholders.

3. Healthcare providers shall be responsible for:

a) Stepping up the application of information technology in medical examination and treatment. Any medical facility that has or is currently developing a management software should cooperate with the social insurance organization in reaching a common agreement on statistical criteria required for medical examination and treatment; Other medical facilities that have no software should study and apply the software developed by the Vietnam Social Security, ensuring there will be a common software for all;

b) Presiding over and cooperating with the social insurance organization in constructing and applying medical service related expense management programs.

Difficulties that arise during the implementation of this Circular should be reported to the Ministry of Health and Ministry of Finance for studying and handling./.

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