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.
Tìm kiếm
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