Quyết định 1399/QD-BHXH

DECISION

INTRODUCTION OF REGULATION ON PROVISION AND REIMBURSEMENT FOR COVERED SERVICES

DIRECTOR GENERAL OF SOCIAL SECURITY ADMINISTRATION OF VIETNAM

Pursuant to the Law No. 25/2008/QH12 on Health Insurance dated November 14, 2008 and the Law amending and supplementing a number of Articles of the Law No.46/2014/QH13 dated June 13, 2014;

Pursuant to the Government's Decree No.105/2014/ND-CP providing details and directives on a number of Articles of the Law on Health Insurance dated November 15, 2014;

Pursuant to the Government’s Decree No.05/2014/ND-CP defining functions, responsibilities, entitlement and organizational structure of Social Security Administration of Vietnam dated January 17, 2014;

Pursuant to the Joint Circular No.41/2014/TTLT-BYT-BTC on guidelines for the application of health insurance dated November 17, 2014;

At request of the Director of the Department of Health Insurance,

HEREBY DECIDES

Article 1. To introduce the regulation on provision of covered services

Article 2. This Decision enters into force from January 01, 2015 and replaces the Decision No.82/BHXH-QD dated January 20, 2010 and Decision No.160/BHXH-QD dated February 14, 2011 by Social Security Administration of Vietnam. Any regulation conflicting with this Decision shall be annulled.

Article 3. The Chief office of the Social Security Administration of Vietnam, Directors of Departments of Health Insurance, heads of affiliates to the Social Security Administration of Vietnam, Directors of North and South Centers for medical assessing and billing , Directors of Social Security Administrations of provinces and centrally-affiliated cities(hereinafter referred to as “province”), Directors of Social Insurances Services affiliated to the Ministry of National Defense and People’s Public Security of Vietnam shall be responsible for the implementation of this Decision ./.

REGULATION

PROVISION OF COVERED SERVICES
(Issued together with the Decision No.1399/QD-BHXH dated December 22, 2014 by the Director General of Social Security Administration of Vietnam)

Chapter I

GENERAL PROVISIONS

Article 1. Scope

This Regulation stipulates the application of health insurance to medical examination and treatment in respect of contracts for provision of covered services, registration for medical facilities, referral and procedures for provision covered services, coverage and rate of health insurance reimbursement (hereinafter referred to as “reimbursement rate”); management, allocation and spending of health funds for covered services (hereinafter referred to as “health fund”), estimation, funding, reimbursement and advance of health funds; reporting forms and required information.

Article 2. Regulated entities

1. The Social Security Administrations of provinces, Centers for medical assessing and billing , Social Security Services of Ministry of National Defense and People’s Public Security of Vietnam (hereinafter referred to as Social Security services of province) and Social Security Administrations of districts.

2. Medical facilities providing covered services (hereinafter referred to as “medical facility”).

3. Organizations, agencies, authorities (hereinafter referred to as “entity”), education institutions under the national education system (hereinafter referred to as “education institution") and relevant individuals.

Article 3. Responsibilities for management and application of health insurance policies

1. The Social Security Administration of Vietnam shall:

a) Issue and manage medical facility codes, update the list of medical facilities and registered medical facilities on the internal website of the Social Security Administration.

b) Direct the Social Security Administrations of provinces to estimate examine and assess the annual estimation of reimbursement for covered services nationwide; allocate and adjust the annual estimation of the amount of reimbursement for covered services within the province and inspect the estimation.

c) Determine and allocate health funds and notify the Social Security Administrations of provinces of 20% of the balance (if any) for the period of from 01/01/2015 to 31/12/2020 in the annual gross insurance premium is more than annual amount of reimbursement.

d) Assess the annual reimbursement amount of provinces.

dd) Manage and regulate health insurance reserve funds (hereinafter referred to as “reserve fund”).

2. Every Social Security Administration of Provinces shall

a) Cooperate with the Departments of Health to

- Identify and make the list of medical facilities qualified for provision of covered services and registered medical facilities under Regulations of the Ministry of Health;

- Determine types of insured persons, their social class and the appropriateness of number of enrollees for the capacity and health fund of registered medical facilities within their province.

- Provide instructions on referral between medical facilities within the province and those in borders between provinces.

b) Cooperate with Departments of Health and Department of Finance to: Prepare plans for allocation of 20% of the remaining health fund and submit them to the People’s Council and People’s Committee of province for approval.

c) Participate in appraising bidding plans and preparing invitation to bid, assessing and evaluating bids for provision of medical equipment, medicines and chemicals under regulations of laws.

d) Direct the Social Security Administrations of districts to carry out estimation of reimbursement within the district and self-estimate reimbursement in the province. Allocate and transfer health funds according to the approved reimbursement estimation to Social Security Administrations of districts.

dd) Appraise the quarter and annual medical expenses of the Social Security Administration of province.

e) Sign contracts for allocation of primary healthcare funds to education institutions.

g) Sign and execute contracts for provision of covered services with medical facilities of all level within the province; examine requirements for reimbursement for medical services rendered by provincial and central level medical facilities that signed contracts with the Social Security Administration of the district, directly reimburse for eligible medical expenses prescribed in Article 16 hereof.

h) Manage and allocate the annual health fund as follows:

- Transfer primary healthcare funds to educational institutions and entities having medical services qualified for the primary healthcare fund.

- Transfer health funds to Social Security Administrations of districts;

- Estimate, advance and reimburse for eligible medical expenses to medical facilities directly signing contracts for provision of covered services with the Social Security Administration of the province;

- Reasonably allocate health funds to medical facilities within the province.

i) Assess the appropriateness of medical services administered to insured persons, identify reasons for cost overruns on the health fund (for insured patients referred to by initiating facilities).

k) Centrally manage health insurance database and medicare coverage database within the province.

l) Aggregate and notify of transfer of intra provincial and extraprovincial reimbursement.

m) Issue the copayment exemption certificate to the insured who buys health insurance for at least 05 consecutive years and his/her copayment is over 06-month statutory base rate ( except for those who intentionally receive medical care at inappropriate levels).

3. Every Social Security Administration of districts shall:

a) Estimate and transfer primary healthcare funds to education institutions and other eligible entities prescribed in Article 18 of the Joint Circular No.41/2014/TTLT-BYT-BTC dated November 24, 2011 by the Ministry of Health and the Ministry of Finance providing guidance on health insurance.

b) Sign contracts for provision of covered services with medical facilities of communes and districts or those at the equivalent levels as stipulated in Article 1 and 2 of the Circular No. 37/2014/TT-BYT on guidelines for initial registration and referral within the coverage of health insurance (except for private hospitals).

c) Directly reimburse for all eligible medical expenses for insured patients whose application is approved by the Social Security Administration of the province.

d) Assess and directly reimburse for eligible medical expenses if the medical expense does not exceed 10 million dong per series of medical treatment, carry out the assessment and notify assessment results at request of the Social Security Administration of the province or other districts.

dd) Issue a copayment exemption certificate to the insured person who buys health insurance from underwriters appointed by the social Security Administration of provinces.

e) Every Social Security Administration of district shall carry out tasks mentioned in point b and d clause 3 of this Article if it satisfies the following requirements:

- At least 01 specialist specialized in assessment of the appropriateness of medical services administered to insured patients obtains 02-year associate degree of medicine or pharmacy or higher;

- There shall be at least 01 accountant in charge of monitoring the payment and reimbursement of medical expenses.

Chapter II

EXECUTION OF CONTRACTS FOR PROVISION OF COVERED SERVICES, INITIAL REGISTRATION, REFERRAL AND PROCEDURES FOR PROVISION OF COVERED SERVICES

Article 4. Contracts for provision of covered services

1. According to the functions, responsibilities and capacity of medical facilities, the Social Security Administration shall sign contracts for provision of covered services as follows:

a) Contracts for provision of outpatient care with medical facilities providing outpatient services;

a) Contracts for provision of outpatient and inpatient care with medical facilities providing outpatient and inpatient services;

2. Contract award criteria

The Social Security Administration shall sign contracts for provision of covered services with medical facilities that are granted medical facility coded by the Social Security Administration of Vietnam under Article 3 of the Decision No.1314/QD-BHXH on issuance of health insurance card codes dated December 02, 2014, and meet all requirements stipulated in Article 42 of the Law on medical examination and treatment, and clause 2, Article 7 of the Joint Circular No.41/2014/TTLT-BYT-BTC and other relevant regulations of laws.

3. Assessment prior to contact award

a) For every medical facility that enters into the first contract for provision of covered services or terminated the last contract for 06 months or longer

- The department specialized in receiving and storing documents (hereinafter referred to as “document-receiving department”) of the Social Security Administration of province or single-window system of Social Security Administrations of districts (hereinafter referred to as “single-window system” shall instruct medical facilities to complete their application for provision of covered services as prescribed in clause 2, Article 7 of the Joint Circular No.41/2014/TTLT-BYT-BTC and transfer such application to the department in charge of assessing the appropriateness of medical services administered to insured patients (hereinafter referred to as “assessing department”) within the set forth deadline in clause 3, Article 9 on social security and health insurance administrative procedures issued together with the Decision No.1366/QD-BHXH dated December 12, 2014 by the Director General of the Social Security Administration of Vietnam;

- With 07 days from the date of receipt, the assessing department shall appraise the eligibility for contract award according to above-mentioned criteria, make out appraisal records using form 02/BHYT enclosed herewith. According to the demand for medical care of insured persons within the province, number of insured persons and health funds, the Social Security Administration of the province shall submit an application for covered service providers’ codes to the Social Security Administration of Vietnam;

- With 07 days from the date of receipt of the application and appraisal record made using form 02/BHYT, the Department of Health Insurance Policy - Social Security Administration of Vietnam shall make such application and record publicly on their internal website and response to the applicant in writing.

b) For medical facilities annually signing contracts for provision of covered services: In case of any adjustments, the Social Security Administration of province shall request medical facilities that provide covered services last year to complete their applications for contracts for provision of covered services under point b, clause 2, Article 7 of the Joint Circular No.41/2014/TTLT-BYT-BTC by December 15^th of every year.

c) Within 30 days from the date of receipt of the complete application, the Social Security Administration shall consider awarding the contract for provision of covered services with eligible medical facility. In case of rejection, the Social Security Administration shall send a written notice in which reasons for rejection shall be specified.

4. Contract award

a) The Social Security Administration and medical facility shall conclude the contract using the form in Annex 03 enclosed with the Joint Circular No.41/2014/TTLT-BYT-BTC and supplement appropriate terms in respect of insured patients’ interests and application for assessment of the appropriateness of medical services administered to insured patients prescribed in clause 6 of this Article according to the functions, responsibilities and capacity of the covered service provider.

b) For medical facilities of district or higher; According to functions, responsibilities and capacity of the medical facility, additional terms of contracts and methods of reimbursement for eligible medical expenses shall be included in the contracts for provision of covered services signed between the Social Security Administration and the medical facility .

c) For maternity wards and health stations of communes eligible for provision of covered services: The Social Security Administration of the district and medical facilities or health stations of district approved by the Department of Health shall negotiate to supplement additional terms in respect of covered services administered by maternity wards and health stations of communes to the contract.

d) For general clinics affiliated to hospitals or health stations of districts: Such general clinic shall conclude a contract for provision of covered services as a department of the hospital or health station of the district. Under regulations on qualifications, profession and schedule of medical services approved by the competent authority, the Social Security Administration and hospitals or health stations of province shall supplement terms in respect of covered services to the contract.

dd) For healthcare services of education institutions and entities (hereinafter referred to as “organizational health service”) other than those funded with primary healthcare funds, the Social Security Administration shall directly sign the contract with such education institution or entity in charge of management of organizational health services. In case of under-provision of medicines, chemicals or medical equipment or services, the Social Security Administration shall sign the contract with hospital or health stations of the district.

5. Contract validity

a) For medical facilities that enter into the first contract for provision of covered services or terminated their last contract for 06 months or longer The contract shall come into effect from the date of signature up to December 31 of the signing year inclusive.

b) For medical facilities annually entering into contracts for provision of covered services: The Social Security Administration and medical facility shall sign the contract by December 31 of the immediately preceding year. The contract shall come into effect from January 01^st to December 31 of that year inclusive.

6. Documents required for assessment of the appropriateness of medical services administered to insured patients.

a) A list of medical services approved by the competent authority

b) A schedule of medical service prices approved by the competent authority.

c) A schedule of medical services prices decided by the medical facility

d) A list of medicines, chemicals and medical equipment for covered services by bidding result or a list of those legally procured in other form or shape; a list of self-prepared medicines and their proposed prices (if any).

dd) Proposals and agreements on cooperation in medical services, employment contracts between the medical facility and practitioners (if any); Decision on technical transfer to lower levels or Decision on medical assistance issued by the competent authority.

e) Lists of reimbursed medical expenses.

g) Other documents related to covered services and reimbursement under clause 2, Article 43 of the Law amending the Law on Health Insurance.

Physical and electronic documents and information for assessment of the appropriateness of covered services administered to insured patients.

7. Contract execution

a) For medical facilities

Every medical facility shall:

- Welcome insured patients and inspect the procedures for covered services provided for insured patients;

- Administer medical services as agreed in the contract for provision of covered services, in case of lack of medicines, chemicals or medical equipment, the medical facility shall reimburse for cost of such medicines, chemical and materials that insured patients buy outside, and submit request for payment to the Social Security Administration under regulation of laws.

- Provide documents required for assessment of the appropriateness of medical services administered to insured patients under clause 6 of this Article; provide insured patients with medical bills which specify copayments and self-payments;

- Promptly notify the Social Security Administration of changes related to the provision of medical services, medicines, medical equipments and substances, and functions and responsibilities of the medical facility in writing.

- Monthly and quarterly submit a list of insured patients using the forms C79a-HD and C80a-HD enclosed with the Circular No.178/2012/TT-BTC dated October 23, 2012 by the Ministry of Finance providing guidance on accounting for social security (make out a list of organ donors without health insurance under treatment after organ donation and list of uninsured patients under the age of 06 enclosed with the copy of their birth certificate or report of birth );

- Effectively manage and use health funds in accordance with regulations of laws. In case of overruns, the medical facility shall submit an explanation to the Social Security Administration within 30 days from the date on which the reimbursement record is signed.

b) For Social Security Administration

Every Social Security Administration shall:

- Cooperate with medical facilities to inspect the procedure for administration of covered services; disseminate health insurance policies and regulations, and deal with issues in relation to insured patient benefits;

- Assess the appropriateness of covered services, advance and reimburse for medical expenses within the coverage of health insurance;

- Promptly notify medical facilities of changes in health insurance codes and estimated funds in writing.

- Examine and respond in writing to the reimbursement in relation to changes in medicines, medical equipment and chemicals, and functions and responsibilities of the Department of Health.

- Quarterly assess the cost overruns and make up deficits under regulations of laws;

- Cooperate with medical facilities to determine the actual average expense by the coverage of an outpatient and inpatient treatment series or by specialty of referrals in the preceding year as the basis for determination of the maximum reimbursement for the receiving facility under clause 6, d 11 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

8. Contract document and report management and retention

a) The assessing department shall retain all contract documents and the Department of Finance and Planning shall keep 01 copy of the contract.

b) The Social Security Administration of the province shall submit a report on contracts for provision of covered services using the form 13/BHYT enclosed herewith to the Social Security Administration of Vietnam by January 15th of every year; and report to the Social Security Administration of Vietnam in case any new medical facility enters into the contract or the medical facility adjust their operation, level or medical services.

Article 5. Registration for medical facilities for covered services

1. The medical facility is entitled to provide covered services if it satisfies requirements stipulated in clause 2, Article 4 hereof and Article 5 of the Circular No.37/2014/TT-BYT.

2. Registered medical facilities

a) Insured persons are entitled to register medical facilities to receive covered services as stipulated in Articles 6 and 7 of the Circular No.37/2014/TT-BYT.

b) Every insured person shall be entitled to register another medical facility at the beginning of every quarter.

3. Procedures for registration

a) The assessing department shall transfer the list of medical facilities qualified for being registered medical facilities in the province to the department of health insurance cards and books, and department of informatics; and submit the list of registered medical facilities providing covered services for insured patients not residing in the province to the Social Security Administration of Vietnam.

b) The document-receiving department shall notify the list of medical facilities qualified for being registered medical facilities to insured person and instruct them to select or change their registered medical facility under clause 2 of this Article.

Article 6. Referral

1. The referral of insured patients shall be made in accordance with Articles 5, 6 and 7 of the Circular No.14/2014/TT-BYT dated April 14, 2014 on referral between medical facilities and Articles 8 and 9 of the Circular No.37/2014/TT-BYT.

The initiating facility shall fill the referral from using the Annex 01 enclosed with the Circular No.14/2014/TT-BYT In case of referral at request of the insured patient, the initiating facility shall follow clause 5, Article 5 of the Circular No.14/2014/TT-BYT.

2. In case of referral prescribed in point b, clause 2, Article 9 of the Circular No.37/2014/TT-BYT the initiating facility shall comply with point a, clause 1, Article 5 of the Circular No.14/2014/TT-BYT for the insured patient interests.

Article 7. Procedures for access to covered services

1. The procedure for access to covered services shall be conformable to Article 8 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

- In case of absence of photo on the health insurance card, insured patients may present other equivalent identification documents such as ID card, passport, membership card of Vietnam’s Communist Party, Military ID card, student card, veteran ID card, driving license or other legal documents enclosed with photos;

- In case of reissue or replacement of health insurance cards, patients shall present a document receipt and follow-up appointment for test result return using the form 01/PH issued together with the Decision No.1366/QD-BHXH. Such appointment shall specify the insured’s information and shall expire after 07 days from the date of issue. The follow-up appointment shall be signed and sealed by the Director of Social Security Administration of districts;

- Any patient who had donated their organ but have not had a health insurance card shall present their hospital discharge form prescribed in point a, clause 2, Article 5 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

2. In case of referral, insured patients shall present the referral from using the Annex 01 enclosed with the Circular No.14/2014/TT-BYT

3. Insured patients shall also present the copayment exemption certificate made using form 05/BHYT enclosed herewith to be exempted from copayments is they receive medical care at appropriate level.

Chapter III

HEALTH INSURANCE COVERAGE

Article 8. Health insurance coverage

Insured patients shall have their following medical expenses covered:

1. Medical examination fees at the price approved by the competent authority.

2. Costs for hospital stays at the price approved by the competent authority if :

a) The insured inpatient is referred from the district medical facility.

b) Insured Inpatients do not stay for more than 03 days at medical stations of communes at the cost approved by the competent authority. For medical stations of disadvantaged communes or islands, insured patients shall not stay for longer than 5 days.

3. Medical expenses at the price approved by the competent authority.

For medical services which are administered by medical staff of superior medical facilities in rotation or under medical professional assistance programs stipulated in regulations of the Ministry of Health but have not priced yet, the expenses shall be covered at the price applied by the superior medical facility that conducts the technology transfer.

4. Costs of medicines, medical equipment and chemicals directly applied to patients by the list at the reimbursement rate and under terms of payment prescribed by the Minister of Health but not included in medical service costs.

5. Costs of blood and blood products prescribed in the Circular No.33/2014/TT-BYT on the ceiling price of standard blood bags and whole blood dated October 27, 2014 by the Ministry of Health.

6. Costs of transport of patients from district medical facilities to the higher level in case of emergency or referral of inpatients prescribed in points d, e, g, h and i, clause 3, Article 12 of the Law on amendments to the Law on Health Insurance.

Article 9. Reimbursement rate

1. Insured patients prescribed in Articles 26, 27 and 28 of the Law on Health Insurance and clauses 4 and 5, Article 22 of the law on amendments to the law on health insurance shall have their medical expenses covered at the following rate:

a) 100% of medical expenses within the coverage of health insurance (do not apply the reimbursement rate decided by the Ministry of Health to some medicines, chemicals, medical equipment and services ), and costs of transport at the reimbursement rate stated in the health insurance card coded No. 1 under the Decision No.1314/QD-BHXH.

b) 100% of medical expenses within the coverage of health insurance (the reimbursement rate of some medicines, chemicals, medical equipment and services is decided by the Minister of Health), and costs of transport at the reimbursement rate stated in the health insurance card coded No. 2 under the Decision No.1314/QD-BHXH.

c) 100% of medical expenses within the coverage of health insurance ( the reimbursement rate of some medicines, chemicals, medical equipment and services is decided by the Minister of Health) if the treatment costs less than 15% of the statutory pay rate or medical examination and treatment is administered by medical facilities of communes.

d) 100% of medical expenses within the coverage of health insurance (the reimbursement rate of some medicines, chemicals, medical equipment and services is decided by the Minister of Health) if the insured patient has been buying health insurance for at least 05 consecutive years and his/her amount of annual copayment is more than 06-month statutory pay rate altogether. Insured patients shall retain all receipt of copayment in order to be granted the copayment exemption certificate.

dd) 95% of medical expenses within the coverage of health insurance (the reimbursement rate of some medicines, chemicals, medical equipment and services is decided by the Minister of Health), costs of transport at the rate of health insurance reimbursement prescribed in the health insurance card coded by No. 3 under the Decision No.1314/QD-BHXH.

e) 80% of medical expenses within the coverage of health insurance (the reimbursement rate of some medicines, chemicals, medical equipment and services decided by the Minister of Health), and costs of transport at the reimbursement rate stated in the health insurance card coded No. 4 under the Decision No.1314/QD-BHXH.

g) 100% of medical expenses including expenses beyond the coverage of health insurance and cost of transport at reimbursement rate prescribed in the health insurance card coded No. 5 under the Decision No.1314/QD-BHXH.

2. Insured patients receiving medical care at medical facilities other than their registered facility without referral form (except for emergencies and cases stipulated in point a, d, c, dd, and e, clause 5 of this Article shall promptly present their health insurance card to be reimbursed for medical expenses under Article 8 and clause 1 of Article 9 at the reimbursement rate as follows :

a) At central hospitals: 40% of medical expenses for inpatient care;

b) At provincial hospitals: 60% of the medical expenses for inpatients receiving medical care from 01/01/2015 to 31/12/2020; 100% of the medical expenses for inpatients receiving medical care from January 01, 2021 onwards;

c) At district hospitals specified in clauses 1, 2, 3, 9 and 10 of the Circular No.37/2014/TT-BYT and district health stations that are not separated from district hospitals (including general clinics affiliated to such medical facilities): 70% of the medical expenses for inpatients receiving medical care from 01/01/2015 to 31/12/2015; or 100% of the medical expenses for inpatients receiving medical care from January 01, 2016 onwards.

3. If insured patients select their caregiver and medical room, the medical expenses shall be reimbursed within the coverage of health insurance at the reimbursement rate prescribed in clause 1 or 2 of this Article.

4. The amount of medical expenses beyond the coverage of health insurance prescribed in Article 8 or reimbursement rate clause 1 of this Article and medical expenses for outpatients prescribed in points a and b , clause 2 and 3 of Article 9 hereof shall be paid by the insured patient.

5. The reimbursement rate is specified as follows:

a) From January 01, 2016 onwards, insured persons registering for medical examination and treatment at health stations of communes or general clinics or district hospitals are entitle to receive medical care administered by other health station of communes, general clinics or district hospitals within the province and shall have medical expenses covered at the reimbursement rate prescribed in clause 1 of this Article.

b) Insured patients holding insurance cards on which the residential address is coded as K1, K2 or K3 and receiving medical care at inappropriate level shall have their medical expenses covered at the district /provincial/central hospital at the reimbursement rate prescribed in point b, clause 1 of this Article.

c) From January 01, 2021 onwards, any insured patient picks one of inappropriate level facilities of district shall have their medical expense covered at the reimbursement rate prescribed in clause 1 of this Article.

d) Post-emergency patients referred to other department or medical rooms or hospitals shall have their medical expense covered at the reimbursement rate prescribed in clause 1 of this Article.

dd) Insured patients receiving medical care at medical facilities within the border of two different provinces under clause 2, Article 4 of the Government’s Decree No.105/2014/ND-CP dated November 15, 2014 detailing and guiding the application of a number of Articles of the Law on Health Insurance or those who are on business trip, work or attend schools or temporarily reside in other provinces for less than12 months shall be entitled to receive medical care at medical facilities that have similar level to the registered facility other permissible facility and shall have their medical expenses covered at the reimbursement rate prescribed in clause 1 of this Article.

e) In case of referral, the insured patients getting their disease not mentioned in the referral form cured shall have medical expenses covered at the reimbursement rate prescribed in clause 1 of this Article. This provision shall not apply to follow-up examination or treatment if the insured patient repeatedly use the referral form made within a fiscal year as stipulated in point d, clause 2, Article 9 of the Circular No.37/2014/TT-BYT.

g) Insured patients requiring medical care on days-off or holidays stipulated in clause 5, Article 13 of the Joint Circular No.41/2014/TTLT-BYT-BTC shall have their medical expenses covered at the reimbursement rate prescribed in clause 1 of this Article. Such insured patients shall pay medical expenses beyond the coverage and reimbursement rate of health insurance (if any).

h) Insured patients receiving medical care at non-public medical facilities shall have their medical expenses covered but not exceeding the reimbursement of the same level public medical facilities.

i) Insured patients receiving medical care at public medical facilities which provide medical services for profit shall have their medical expense covered under regulations of laws but not exceeding the reimbursement approved by the competent authority.

k) Costs of patient transport shall be reimbursed as stipulated in clause 1, Article 13 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

Chapter IV

MANAGEMENT, ALLOCATION AND SPENDING OF HEALTH FUNDS

Article 10. Management, allocation and spending of health funds

1. Health funds

a) The health fund shall account for 90% of the total annual health insurance premium calculate in accordance with Article 2 of the Decree No.105/2014/ND-CP and total unexpired insurance cards (hereinafter refer to as "total annual premium")

b) The social Security of Vietnam shall manage health funds and promptly and sufficiently transfer to the Social Security Administrations of provinces. Health fund shall be allocated to:

- Medical expenses within the coverage under the Law on health insurance and other guidance;

- Primary healthcare funds to education institutions and medical facilities that are eligible for funding for primitive healthcare under Article 18 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

2. Reserve funds for covered services

a) The reserve fund is constituted from:

- The remaining of 10% of the total annual premium after allocation to the administrative expense but not less than 5%.

- Earnings from investment of temporary idle premium funds;

- 80% of the remaining health funds for the period of from 01/01/2015 to 31/12/2020 ; or 100% of the health funds since 01/01/2021 onwards;

- Premium outstanding debts of previous years collected;

- Fines for premium late payment prescribed in point a, clause 3 of Article 49 of the laws on amendments to the Law on Health Insurance;

- Reimbursements that were finalized in the immediately preceding year returned to the health insurance fund under the decision of the competent authority.

b)Reserve funds shall be centrally managed by the Social Security Administration of Vietnam and shall be used for raising health i funds of social Security Administrations of provinces where the total premium is less than the total reimbursement.

c) The remaining reserve fund shall be included in the next year reserve fund under point b of this clause.

Article 11. Estimation and transfer of primary healthcare funds

1. The document-receiving department shall instruct education institutions and entities to submit the application for primary healthcare funding using form 01/BHYT enclosed herewith to the Social Security Administration by October 31 of every year.

2. Single-window department shall receive such applications and transfer them to the document-receiving department.

3. Document-receiving department shall process such applications as follows:

- For education institutions: Within 02 working days, according to the number of students buying health insurance, the education institution shall submit a list of students applying for health insurance using the form D03-TS issued together with the Decision No.1111/QD-BHXH dated October 25, 2011 by the Director General of Social Security Administration of Vietnam, a list of students holding health insurance by special group using form 03/BHYT enclosed herewith, list of under-06-year-old children (including all children under the age of 06 within the locals or children being relatives of those prescribed in point a, clause 3, d 12 of the Law on amendment to the Law on health Insurance) to the Department of Finance and Planning (or Accounting department).

- For relevant entities: The document-receiving department shall monthly calculate the premiums of their workers and submit the premium calculation sheet to the Department of Finance and Planning (or Accounting department).

4. Department of Finance and Planning (or Accounting Department) shall:

a) Take charge of awarding contracts and transferring primary healthcare funds to education institutions using form C84a-HD enclosed with the Circular No.178/2012/TT-BTC by the first month of the academic year or course; and adjust the primary healthcare fund according to the actual premiums and finalize the contract using form C84b-HD enclosed with the Circular No.178/2012/TT-BTC at the end of the fiscal year.

b) Monthly transfer the primary healthcare fund to the unit that paid for their workers’ premiums

c) Include the primary healthcare fund in the annual reimbursement of the province.

5. The assessing department shall periodically or surprisingly inspect the allocation of primary healthcare fund by education institutions and entities under Article 18 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

Article 12.Health funds at Social Security Administration of provinces

1. The health fund at the Social Security Administration of the province is raised from the remaining budget of 90% of annual premium prescribe in clause 1, Article 6 of the Decree No.105/2014/ND-CP.

2. The health fund is allocated for:

a) Primary healthcare stipulated in clause 2, Article 17 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

b) Referral under Article 14 hereof

The remaining healthcare fund directly held by the Social Security Administration of the province including:

- 55% of health funds of medical facilities signed contracts for provision of covered services for outpatients; 10% of health funds of medical facilities signed contracts for provision of covered services for outpatients and inpatients

- The remaining health fund after transferring to the medical facility similar to health stations of communes;

- The remaining health fund after transferring fixed amount to medical facilities requiring payment by capitation;

- The remaining capitation fund after deduction from the amount of transfer to medical facilities under point b, clause 1, Article 10 of the Joint Circular No.41/2014/TTLT-BYT-BTC; and the remaining health fund of medical facilities requiring fee-for-service payment (if any);

- 90% of premiums paid by holders of health insurance cards which are issued or registered at other provinces.

Article 13. Management and allocation of health funds directly managed by the Social Security Administrations of provinces

Health fund specified in point c, clause 2; Article 12 hereof is used for reimbursing for:

1. Medical expenses for inpatient care at registered medical facilities signed contracts for provision of outpatient care.

2. Medical expenses for medical care at medical facilities other than registered facilities.

3. Expenditures beyond the capitation fund

4. Medical expenses of insured patients whose registered medical facility is located at a different province.

5. Previous year medical expenses of fee-for service medical facilities which are permitted to be finalized in this fiscal year.

6. Health funds of medical facilities where come in over budget due to force majeure events or objective causes.

Article 14. Health funds of medical facilities

1. Determination of health fund for registered medical facilities

The health fund for registered medical facilities shall be determined according to the contract for provision of covered services. To be specific:

a) For fee-for service medical facilities:

- The total health fund of the province is determined under clause 1, Article 12 hereof;

- Total primary healthcare fund of the province is determined under clause 2 of Article 17 of the Joint Circular No.41/2014/TTLT-BYT-BTC;

- Number of health insurance cards per year shall be equal to the total number of health insurance cards which are valid counted as at the end of every month divided by 12;

- Number of health insurance holders registering the medical facility are exclusive of health insurance holders whose cards are issued by Social Security Administration of other provinces. For medical facilities designated to administer medical examination and treatment at health stations of communes, the number of health insurance holder registering the medical facility are inclusive of those registering health stations of communes;

- For registered medical facilities signed contracts for covered outpatient services, the health fund shall account for 45% of health funds of other medical facilities;

- For registered medical facilities executing contracts for covered outpatient and inpatient services, the health fund shall account for 90% of health funds of other medical facilities;

b) The health fund for registered fee-for-service medical facilities shall be quarterly determined as follows:

- By the fifth of the beginning of every quarter, the document-receiving department shall take charge of and cooperate with the Department of Health Insurance Cards and Books shall calculate the average number of cards in the previous quarter ; the number of cards firstly registered for every medical facility within the province and the amount of premiums of previous quarter using form B05-TS issued together with the Decision No.1111/QD-BHXH and report to the Department of Finance and Planning and assessment department. The average number of cards in the previous quarter equals (=) total of health insurance cards counted at the end of the previous quarter divided by (:) 03;

- According to the aforesaid form B05-TS, the Department of Finance and Planning shall take charge of and cooperate with the assessing department to determine the health fund (after deduction from primary healthcare funds) and send the medical facility a notification of health fund and medical expenses using the form C81-HD issued together with the Circular No.178/2012/TT-BTC within 30 days from the date of receipt of quarter financial statement from the medical facility.

- The Department of Finance and Planning shall adjust the health fund and notify the medical facility of adjustment (if any) in the fourth quarter of every year. The annual health fund shall be the sum of quarter health funds altogether.

c) For medical facilities applying capitation system:

- The capitation fund is determined under clauses 2 and 3, Article 10 of the Joint Circular No.41/2014/TTLT-BYT-BTC;

- Capitation rate is determined on the basis of inpatient and outpatient medical expenses which has been finalized.

- The assessing department shall cooperate with the Department of Finance and Planning to regulate capitation fund for the medical facility by the year ended on the basis of adjustment coefficient and expenditures incurring beyond the designated budget.

- The assessing department, after finalization of medical expenses for covered services, shall annually aggregate medical expenses by type of covered service as the basis for determination of the following year capitation rate.

2. Management and allocation of health fund by registered medical facilities

a)The health fund of registered medical facilities shall be used for reimbursing for covered service expenses including those which will be directly reimbursed by the Social Security Administration and costs of transport (if any).

b) The registered medical facility shall be entitled to manage and allocate the capitation fund for provision of covered services for insured patients in accordance with clause 4, Article 10 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

c) Any covered service expense of the previous year which is reimburse in the current year by the Social Security Administration of Vietnam shall be included in the capital fund of the current year.

3. Funding for covered services at health stations of communes or organizational healthcare services

a) Covered services at health stations shall be funded with the health fund of the medical facility designated to administer covered services at health stations of communes within their administration under point a, clause 4, Article 7 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

b) The funding for covered services administered at organizational healthcare departments which are similar to health stations of communes shall occupy at least 10% of the covered outpatient care fund but shall not exceed 20% of the covered outpatient care calculated by number of registering holders. Such funding shall be used for reimbursing for expenses of covered services administered to their staff receiving medical care at the organizational healthcare department .

Chapter V

ADVANCE, SETTLEMENT AND FINALIZATION OF HEALTH FUNDS

Article 15. Advance, reimbursement and finalization of health funds

1. Advance of health funds

a) After receipt of the financial statement (using form 79a-HD or 80a-HD) of the previous quarter of the medical facility, the assessing department shall submit a request for advance using form 12/BHYT enclosed herewith to the Department of Finance and Planning (or accounting department).

Within 05 working days from the date of receipt of the request, the Department of Finance and Planning (or accounting department) shall make a lump-sum advance of 80% of the medical expenses stated in the previous quarter financial statement.

b) Procedures for advance

- By the fifth of the first month of every quarter, the Department of Finance and Accounting shall give an advance of at least 80% of the medical expenses stated in the previous quarter financial statement to the Social Security Administration of the province.

- By the 17^th of the first month of every quarter, the Department of Finance and Planning shall submit an aggregate report on advance requests by medical facilities within the province using form12/BHYT to the Social Security Administration of Vietnam;

- Within 02 working days from the date of receipt, the Department of Finance and Accounting shall arrange to give an advance of 80% of the medical expenses stated in the previous quarter financial statement to the Social Security Administration of the province.

2. Transfer of health funds

a) By 15^th of the second months of every quarter, the Department of Finance and Planning shall take charge of and cooperate with the assessing department to determined health fund and submit the quarter medical expense statement using the form 15/BHYT enclosed herewith to the Social security Administration of Vietnam.

b) Within 05 working days from the date of receipt, the Department of Finance and Accounting shall arrange to give an advance of 80% of health fund to the Social Security Administration of the province.

c) Within 05 working days from the date of receipt, the Social Security Administration of Vietnams shall settle sufficient reimbursements to medical facilities and report to the Department of Finance and Accounting - Social Security Administration of province in writing.

3. Settlement and finalization of health funds to medical facilities

Under terms of contracts for provision of covered services, documents and medical bills specified by the Ministry of Finance, the Social Security Administration shall finalize and reimburse all medical expenses for covered services to medical facilities under point a, b and c, clause 2, Article 32 of the Law on amendments to the Law on Health Insurance. To be specific:

a) Every medical facility shall monthly submit a electronic and physical list of insured patients requesting to receive reimbursement in the previous month (using form C79a-HD and C80a-HD issued together with the Circular No.178/2012/TT-BTC); list of medical equipment which are quarterly funded with health insurance fund and applied to insured inpatients and outpatients using form 19/BHYT, list of medicines quarterly administered to insured outpatients and inpatients using form 20/BHYT and list of medical services administered to insured inpatients and outpatients using form 21/BHYT issued together with this Decision to the assessing department for determination of medical expense reimbursement.

b) Quarterly, the assessing department shall:

- Make out a list of insured patients approved to be reimbursed using form C79b-HD and C80b-HD issued together with the Circular No.178/2012/TT-BTC; and transfer the list of uninsured under-06-year-old patients enclosed with their report of birth or certificate of birth, lists of uninsured organ donors receiving treatment after transplantation to the department of health insurance cards –books for issue of health insurance cards as stipulated in point b, clause 2 or point b, clause 3, Article 13 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

- Balance and allocate quarter health funds for reimbursement for medical expenses to intra and extraprovincial medical facilities to reimburse for medical expenses incurring in the previous quarter to registered medical facilities ;

- By 15^th of the second month of every quarter, submit all documents made using forms 14/BHYT, 19/BHYT, 20/BHYT and 21/BHYT, physically and electronically, to the Department of Health Insurance Policy – Social Security Administration of Vietnam; and those made using forms19/BHYT, 20/BHYT and 21/BHYT , physically and electronically, to the Department of Pharmacy and medical equipment-Social Security Administration of Vietnam.

c) The Department of Finance and Planning (or accounting department) shall quarterly take charge of and cooperate with the assessing department to:

- Determine health fund, amount of advance and reimbursement for medical facilities according the health budget and the maximum reimbursement for receiving facilities;

- Notify the assessment results to the medical facility using forms C79b-HD, C80b-HD, C81-HD or C82-HD issued together with the Circular No.178/2012/TT-BTC within 30 days from the date of receipt of the financial statement of the medical facility;

- With the 10 following days, sign the reimbursement record using form C82-HD issued together with the Circular No.178/2012/TT-BTC and completely settle reimbursement to medical facilities

4. Settlement and finalization of medical expenses to medical facilities which came in over budget

a) For medical facilities that go over budget: within 20 days from date of receipt of the explanation, the assessing department shall take charge of and cooperate with the department of Finance and Planning and relevant departments to assess and identify causes of cost overruns. Any cost overrun on health funds due to objective causes or force majeure events shall be included in the next quarter balance sheet. Overruns on capitation fund due to objectives causes or force majeure events shall be reimbursed at least 60%.

b) Any medical facility that provides outpatient and inpatient care having a deficit shall quarterly be made up with 10% of the remaining health fund; and those providing only outpatient care shall be funded with up to 5% of the remaining healthcare; In case deficits still exist after being made up, the Social Security Administration of province shall make up such deficit with the health fund of the province. In the event that the health fund of the province is not sufficient to make up such deficit, the Social Security Administration of province shall submit a report on cost overrun assessment to the social security Administration of Vietnam.

c) Any Social security Administration of province faces deficits shall submit a report on cost overrun assessment to the social security Administration of Vietnam by April 30 of the following year.

d) By August 30 of every year, the Department of Health Insurance Policy shall take charge of and cooperate with relevant agencies to inspect and assess causes of cost overruns according to the report submitted by the Social Security Administration of the province, and request the Director General of the Social Security Administration of Vietnam to consider approving for using the reserve fund for making up for the deficit.

dd) Within 03 working days from the date of receipt of the approval, the Department of Finance and Accounting shall transfer money to the Social Security Administration of the by the Social Security Administration of Vietnam and shall be used for raising health insurance funds of social Security Administrations of province.

e) Within 05 working days from the date of receipt, the Social Security Administration of the province shall reimburse for medical facilities and report to the Department of Finance and Accounting - Social Security Administration of province in writing.

Article 16. Direct reimbursement

1. Cases eligible for direct reimbursement

The Social security Administration shall directly reimburse for medical expenses for insured patients prescribed in Article 14 of the Joint Circular No.41/2014/TTLT-BYT-BTC.

2. Applications for direct reimbursement

The application for direct reimbursement shall be conformable to Article 15 of the Joint Circular No.41/2014/TTLT-BYT-BTC; or enclosed with the power of attorney or certificate of legal representative if the applicant is patient’s guardian.

3. Direct reimbursement rate

The direct reimbursement rate shall be conformable to clause 3, Article 16 of the Joint Circular No.41/2014/TTLT-BYT-BTC To be specific:

a) Insured patients receiving emergency care at medical facilities not signing contracts for provision of covered services shall have their actual medical expense covered within the coverage of the health insurance prescribed Article 8 at the reimbursement rate prescribed in clause 2, Article 9 hereof.

b) Insured patients receiving medical care other than emergency at medical facilities not signing contracts for provision of covered services shall have their actual medical expense covered within the coverage of the health insurance prescribed Article 8 at the reimbursement rate prescribed in clause 2, Article 9 hereof but not exceeding the reimbursement rate prescribed in the Article 4 enclosed with the Joint Circular No.41/2014/TTLT-BYT-BTC

c) Insured patients receiving medical care at medical facilities which enter into contracts for provision of covered services but not presenting all required documents shall have their medical expense covered within the coverage stipulated in Article 8 at the reimbursement prescribed in clause 2, Article 9 hereof.

4. Organizations in charge of direct reimbursement

Single-window department shall:

- Receive and examine applications for direct reimbursement transfer and instructed insured patients to provided complete application under clause 2 of this Article and copy all documents specified in clause 9, Article 8 of the Joint Circular No.41/2014/TTLT-BYT-BTC collate with the originals and countersign such copies and issue an appointment form to the applicants

- Transfer applications for direct reimbursement to the accessioning department within the same working day.

b) The assessing department shall

- Make out the written request for assessment using form 07/BHYT enclosed herewith within 02 working days in case insured patients receive medical care at facilities out of the province.

- Complete the assessment and send the applicant for request a notification of assessment results and medical expense schedule issued under the Decision No.3455/QD-BYT dated September 16, 2013 by the Minister of Health within 25 days;

- Within 03 days from the date of receipt of the assessment results, the assessing department shall submit a list of medical expenses directly covered using form C78-HD issued together with the Circular No.178/2012/TT-BTC to the Department of Finance and Planning.

c) The Department of Finance and Planning (or Accounting Department) shall:

- Examine the validity of medical bills, documents and applications for direct reimbursement and transfer them to the single-window department within 02 days from the date of receipt of the list of medical expensed directly covered.

- Quarterly submit the integrated list of the list of medical expenses directly covered to the assessing department. The assessing department shall have the registered medical facility deduct such directly covered medical expenses from the health fund.

5. The Social Security Administration shall receive application for direct reimbursement for covered services in the fiscal year up to the end of the first quarter of the following year. In case of under-provision of medicines, and medical equipment, the medical facility shall reimburse for medicines and medical equipment which insured patient purchased outside, and report to the Social Security Administration for payback thereafter. The Social Security Administration of provinces shall make this Regulation publicly to insured persons.

Article 17. Transfer of reimbursements

1. Principles:

a) Intra-provincial reimbursement herein refers to the transfer of reimbursement for medical expenses of insured patients receiving medical care at medical facilities other than their registered medical facility within the province where their health insurance card is issued.

b) Extra-provincial reimbursement herein refers to the transfer of reimbursement for medical expenses of insured patients receiving medical care at medical facilities in provinces other than the province where their health insurance card is issued.

c) Transfer of reimbursement for primary healthcare expenses refers to the transfer of reimbursement if insured students receiving medical care at medical facilities in provinces other than the province where their health insurance card is issued.

2. Transfer of reimbursement to receiving facilities

a) Receiving medical facilities prescribed in points a and b, clause 1 of this Article shall be have their covered service expenses reimbursed. The maximum reimbursement shall be determined in accordance with clause 6, Article 11 of the Joint Circular No.41/2014/TTLT-BYT-BTC

For medical facilities entering into contracts for provision of covered services for the first time, the maximum reimbursement shall be determined according the average medical expenses of the previous year by specialty administered by in-network medical facilities.

b) The Social Security Administration shall quarterly transfer there imbursement to receiving medical facilities for covered services corresponding to the actual covered medical expenses within the coverage of health insurance but the reimbursement shall not exceed the maximum reimbursement deducted copayments.

In case of cost overruns, the assessing department shall take charge of and cooperate with relevant departments to indentify causes of overruns within 30 days from the date of receipt of the explanation of the receiving medical facility. The cost overruns (if any) shall be included reimbursed on the next quarter.

The Social Security Administration shall balance the reimbursement between quarters in the year and adjust reimbursement for out-of-pocket expenses. Out-of-pocket expenses shall not be reimbursed.

3. Notification of intra-provincial reimbursement

a) Within 25 days from the date of receipt of physical and electronic documents made using for C79a-HD and C80a-HD issued together with the Circular No.178/2012/TT-BTC the Social Security Administration of district shall assess and transfer them to the assessing department to calculate inpatient and outpatient care expenses of medical facilities using form 14/BHYT issued together with this Decision.

b) Within 05 days from the date of receipt of data and report of the Social Security Administration of district, the assessing department shall compare medical data to health insurance data of the whole province; refuse to reimburse or request to carry out re-assessment in the absence of information or where information is incorrect. The assessing department shall notify of reimbursement transfer to the Social Security Administration of the district.

4. Notification of extraprovincial reimbursement transfer

a) By 15^th of the second month of every quarter, the Social Security Administration of provinces shall submit both electronic and physical integrated sheet of extra province reimbursement using form No.11/BHYT issued together with this decision to the North Center for medical assessing and billing - Social Security Administration of Vietnam.

b) by 30^th of the second month of every quarter, the North Center for medical assessing and billing shall assess and notify of reimbursement transfer to the Social Security Administration of provinces using form C88-HD issued together with the Circular No.178/2012/TT-BYT physically and electronically. The North Center for medical assessing and billing may refuse to make payment in case the information provided in request for reimbursement transfer is incorrect or incomplete.

c) After receipt of reimbursement transfer notification, the Social Security Administration of the province where the health insurance card is issued shall compare information of the insured patient who received medical care at medical facilities out of the province with medical data in the province and health insurance data. The Social Security Administration of the province may request a re-assessment in case the health insurance card is not available in the health insurance or referral data, or the date of treatment is treasonable; and allocate funding for extra-provincial indirect reimbursement that shall be deducted from health fund of registered medical facilities.

5. Re-assessment of extra-provincial reimbursement transfer

a) Within 15 days from the date of receipt of reimbursement transfer notification, the Social Security Administration where the health insurance card is issued shall double-check reimbursement data and submit a request for re-assessment (where necessary) to the North Center for medical assessing and billing.

b) Within 30 days from the date of receipt of the request for re-assessment, the Social Security Administration of the province where the insured patient came for medical care shall reply in writing.

In case the medical facility where the medical care is administered fails to prove the accuracy of assessment results. The reimbursement shall be included in the finalized medical expenses and next quarter extraprovincial reimbursement amount may be deducted.

c) In the event that the Social Security Administration of the receiving province does not respond to the re-assessment request, the North Center for medical assessing and billing shall adjust the reimbursement in the next quarter.

d) By March 31^st of every year, the North Center for medical assessing and billing shall aggregate the previous year reimbursement transfer notification and submit it to the Social Security Administration of Vietnam (the Department of Finance and Accounting and the Department of Health Insurance Policy) and the Social Security Administration of the province as the basis for adjustment to extra-provincial reimbursement for registered medical facilities and aggregation to medical expenses of the Social Security Administration of the province.

Chapter VI

REPORTING REGIME, FORMS AND DOCUMENTS

Article 18. Reporting forms and documents

Required documents and reporting forms include:

1. Forms issued by the Ministry of Health and Ministry of Finance.

Forms No.C78-HD, C79a-HD, C79b-HD, C80a-HD, C80b-HD, C81-HD, C82-CONTRACT and C86-HD issued together with Circular No.178/2012/TT-BTC are adjusted in the Annex 02 issued together with this Decision.

2. Forms and instructions presented in Annex 01 issued together with this Decision.

Article 19. Reporting regime

1. Social Security Administrations, medical facilities, and relevant agencies using primary healthcare fund shall submit reports physically and electronically under regulations of laws and shall be legally responsible for the legitimacy and accuracy of their information and report.

2. Social Security shall retain all documents and records under regulations of laws.

Article 20. Terms of reference

In case any legislative documents referred to this Regulation is amended or supplemented, the new one shall prevail. /.