Bản dịch văn bản 21/2005/TTLT/BYT-BTC
thong-tu-lien-tich-21-2005-ttlt-byt-btc
Cơ quan ban hành: Bộ Tài chính
Ngày ban hành: 2005-07-27

JOINT CIRCULAR Guiding the implementation of compulsory medical insurance Pursuant to the Medical Insurance Regulation issued together with the Government's Decree No. 63/2005/ND-CP of May 16, 2005, The Ministry of Health and the Ministry of Finance hereby jointly guide the implementation of compulsory medical insurance as follows: PART I MEDICAL INSURANCE PREMIUM PAYERS AND LEVELS, PAYMENT RESPONSIBILITIES AND MODES I. MEDICAL INSURANCE PREMIUM PAYERS AND LEVELS, PAYMENT RESPONSIBILITIES AND MODES Compulsory medical insurance premium payers and levels, payment responsibilities and modes are specified as follows: 1. Vietnamese laborers (hereinafter referred to as laborers for short) working under labor contracts with a term of full 3 months or more and labor contracts with an indefinite term in the following enterprises, agencies and organizations: a/ Enterprises established and operating under the State Enterprise Law, including production/business enterprises, public-utility enterprises and the armed forces' enterprises; b/ Enterprises established and operating under the Enterprise Law, including limited liability companies, joint-stock companies, partnerships, and private enterprises; c/ Enterprises established and operating under the Law on Foreign Investment in Vietnam, including joint-venture enterprises and enterprises with 100% foreign investment capital; d/ Enterprises in the fields of agriculture, forestry, fishery and salt-making; e/ Cooperatives established and operating under the Cooperative Law; f/ Enterprises of political organizations or socio-political organizations; g/ State agencies, non-business units, the armed forces, political organizations, socio-political organizations, socio-political-professional organizations, socio-professional organizations, other social organizations (including organizations and units licensed to conduct production, business or service-provision activities under Party agencies, mass organizations or mass associations, which self-finance their activities); h/ Commune, ward or township health stations; i/ Public preschools; j/ Foreign agencies and organizations or international organizations based in Vietnam, except otherwise provided for by international treaties or multilateral or bilateral agreements to which the Socialist Republic of Vietnam has signed or acceded; k/ Semi-public, people-founded and private establishments in the cultural, health, educational, training, scientific, physical training and sport, and other non-business sectors; l/ Other organizations employing laborers, which are lawfully established and operate; Laborers defined in Clause 1 above, if working under labor contracts with a term of less than 3 months and, upon the expiration of the labor contracts, continuing to work or enter into new labor contracts with labor users, must participate in compulsory medical insurance. For the subjects defined in Clause 1 above, their monthly medical insurance premiums shall be equal to 3% of their monthly salaries according to their rank, grade and position or wages stated in labor contracts plus position-based allowances, working seniority allowances, beyond-bracket seniority allowances, region-based allowances, and difference coefficient in reservation (if any), of which 2% shall be paid by agencies, units, organizations or enterprises (hereinafter referred collectively to as labor users) and 1%, by laborers. Labor users shall have to pay medical insurance premiums for laborers falling under their responsibilities and collect medical insurance premiums from laborers at the set percentages for monthly payment to social insurance agencies. The State encourages labor users in enterprises to fully pay medical insurance premiums for laborers. In this case, 2% of such medical insurance premiums shall be accounted into production costs and 1% shall be covered by the enterprises' funds. 2. For public employees and servants defined in the Ordinance on Public Employees, their monthly medical insurance premiums shall be equal to 3% of their monthly salaries according to their rank, grade and position plus position-based allowances, working seniority allowances, beyond-bracket seniority allowances, region-based allowances, and difference coefficient in reservation (if any), of which 2% shall be paid by their managing agencies and 1%, by public employees and servants themselves. Agencies managing public employees and servants shall have to deduct and collect medical insurance premiums from public employees and servants at the set percentages for monthly payment to social insurance agencies. Salaries, wages and allowances for payment of medical insurance premiums for the subjects defined in Clauses 1 and 2 above shall be the same as those for payment of social insurance premiums. 3. For subjects who are pensioners or provided with monthly working capacity loss allowances, their monthly medical insurance premiums shall be equal to 3% of their pensions or working capacity loss allowances. Social insurance agencies shall make lists of, and pay the whole 3% for, such subjects. 4. For commune, ward or township cadres who have retired and are enjoying monthly social insurance allowances under the Government's Decree No. 09/1998/ND-CP of January 23, 1998, people enjoying social insurance allowances under the Prime Minister's Decision No. 91/2000/QD-TTg of August 4, 2000, people enjoying monthly allowances for labor accidents or occupational diseases other than those participating in other forms of medical insurance; and rubber workers who have retired and are enjoying monthly social insurance allowances, their monthly medical insurance premiums shall be equal to 3% of the common minimum salary. Social insurance agencies shall make lists of, and pay the whole 3% for, such subjects. The state budget shall provide fund for medical insurance premium payment for the subjects who have retired and are enjoying pensions or social insurance allowances before October 1, 1995. The Social Insurance Fund shall cover the medical insurance premium payment for the subjects who have retired and are enjoying pensions or social insurance allowances as from October 1, 1995. 5. For incumbent National Assembly deputies and People's Council deputies at all levels, who are not on the state payrolls or payrolls of socio-political organizations or not enjoying monthly social insurance regime other than those participating in other forms of compulsory medical insurance, their monthly medical insurance premiums shall be equal to 3% of the common minimum salary. Provincial/municipal People's Councils shall make lists of, and pay medical insurance premiums for, National Assembly deputies of local National Assembly delegations. The People's Council of each level shall have to make the list of, and pay medical insurance premiums for, deputies of the People's Council of such level. The state budget shall provide funds for medical insurance premium payment for these subjects according to current state budget decentralization. 6. People with meritorious services to the revolution who are enjoying monthly preferential social allowances according to regulations other than those participating in compulsory medical insurance specified in Clauses 1, 2, 3, 4 and 5 above, including: a/ Persons who had participated in revolutionary activities before August 1945; b/ Spouses, blood fathers, blood mothers, children of martyrs, martyr-nurturing people; c/ Armed force heroes and heroines, labor heroes and heroines, Vietnamese heroic mothers; d/ War invalids, people enjoying policies like war invalids who have lost their working capacity by 21% or more due to injuries, including class-B war invalids, with certification as from December 31, 1993 backward. e/ Revolution activists or resistance war activists who were imprisoned by the enemy, with certification according to regulations; f/ Diseased soldiers who have lost their working capacity by 61% or more due to their ailments, including grade-3 diseased soldiers, who have lost their working capacity by between 41% and 60%, with certification as from December 31, 1994 backward; g/ People with meritorious services to the revolution; h/ People enjoying service allowances and first and second children under 18 years old of war invalids or diseased soldiers, who have lost their working capacity by 81% or more; i/ Other subjects as provided for by law. Monthly medical insurance premiums of the above-said subjects shall be equal to 3% of the common minimum salary. The Labor, War Invalids and Social Affairs agencies shall make lists of, and pay the whole 3% for, such subjects from the state budget. 7. For resistance war combatants and their blood children affected by toxic chemicals used by the US during the war in Vietnam and currently enjoying monthly allowances, their monthly medical insurance premiums shall be equal to 3% of the common minimum salary. The Labor, War Invalids and Social Affairs agencies shall make lists of, and pay the whole 3% for, such subjects from the state budget. 8. For old and weak commune cadres who have retired and are enjoying monthly allowances under Decision No. 130/CP of June 20, 1975, of the Government Council (now the Government) and Decision No. 111/HDBT of October 13, 1981, of the Council of Ministers (now the Government), their monthly medical insurance premiums shall be equal to 3% of the common minimum salary from commune, ward or township budgets (hereinafter referred collectively to as commune budgets). The People's Committees of the communes, wards or townships where the subjects are enjoying the allowances shall make lists of such subjects, register them with social insurance agencies and pay the whole 3% for them. 9. Relatives of people's army officers on active service; relatives of professional officers working in the people's police force other than those participating in other forms of compulsory medical insurance, including: a/ Blood fathers and mothers of officers; blood fathers and mothers of officers' spouses; b/ Adoptive fathers and mothers or lawful fosterers of officers or of officers' spouses; c/ Spouses of officers; d/ Under-18 blood children and lawfully adopted children of officers; blood children and lawful adopted children of officers, aged full 18 years or older but disabled, thus having no working capacity under the provisions of law. Monthly medical insurance premiums of officers' relatives shall be equal to 3% of the common minimum salary. The Ministry of Defense and the Ministry of Public Security (after reaching agreement with the Ministry of Health and the Ministry of Finance) shall guide the responsibilities for, and modes of, payment of medical insurance premiums for these subjects. 10. For social policy beneficiaries, their monthly medical insurance premiums shall be equal to 3% of the common minimum salary. - Commune People's Committees shall make lists of, and pay the whole 3% for, social policy beneficiaries enjoying monthly allowances and living in communities from commune budgets. - Nurturing centers and social relief centers shall make lists of, and pay the whole 3% for, the subjects living in the centers from the state budget allocated to the centers. 11. For people aged 90 years or older and helpless disabled elderly people, who are provided with monthly allowances in the communities or nurtured in concentrated nurturing establishments (other than those participating in other forms of compulsory medical insurance), their temporary medical insurance premiums shall be VND 50,000/person/year. - Commune People's Committees shall make lists of, and pay medical insurance premiums according to regulations for, the subjects residing in communes from commune budgets. - Nurturing establishments shall make lists of, and pay medical insurance premiums for, the subjects nurtured at the establishments from the state budget allocated to such establishments. 12. For people entitled to medical examination and treatment (MET) for the poor, their temporary medical insurance premiums shall be VND 50,000/person/year. The Labor, War Invalids and Social Affairs agencies shall make lists of, and pay medical insurance premiums for, these subjects from the state budget. 13. For war veterans in anti-French and anti-US wars, apart from the subjects participating in compulsory medical insurance mentioned above, including armymen and defense workers who had been engaged in combat or served combat in Vietnam People's Arm Forces units before April 30, 1975, their monthly medical insurance premiums shall be equal to 3% of the common minimum salary, which shall be covered by the state budget. The War Veterans' Associations of the localities where the subjects reside shall make lists of these subjects and send them to commune, ward or township People's Committees for further sending to district-level War Veterans' Associations. District-level War Veterans' Associations shall sum up and submit them to provincial-level War Veterans' Associations for approval and reporting to provincial-level People’s Committees for budget allocation according to current budget decentralization. 14. For foreign students who are studying in Vietnam with the Vietnamese State's scholarships, their medical insurance premiums shall be equal to 3% of their monthly scholarships; the scholarship-granting agencies shall make lists of, and pay the whole 3% for, these subjects. II. ISSUANCE, MANAGEMENT AND USE OF MEDICAL INSURANCE CARDS 1. Medical insurance cards shall be issued by social insurance agencies to medical insurance participants, determining that their bearers shall be entitled to medical insurance benefits within the duration stated in the cards. Medical insurance cards shall be issued and uniformly managed nationwide by Vietnam Social Insurance. 2. Each participant in compulsory medical insurance shall be issued only one medical insurance card. In cases where a person falls within two or more subjects participating in compulsory medical insurance, one of the subjects shall be selected according to the order specified in Section I, Part I of this Circular, and such person shall enjoy medical insurance benefits of the subject having the highest benefits. Agencies, units or organizations shall make lists of subjects and social insurance agencies shall have to examine such lists, in order to avoid overlap of subjects. 3. Medical insurance cards shall be valid for immediate and continuous use as soon as medical insurance premiums are paid strictly according to regulations. In order to ensure the continuing validity of medical insurance cards, agencies, units, organizations or labor users shall have to register the extension of medical insurance cards and notify social insurance agencies of the changes of subjects under their respective management. The issuance, replacement and renewal of cards by social insurance agencies must ensure continuity and timeliness, without affecting the benefits of medical insurance participants. 4. Medical insurance cards shall be invalid in the following cases: a/ They are issued not by social insurance agencies; b/ They have expired; c/ They have been modified, erased, torn,' d/ Their bearers have died or are being jailed; e/ They are used by people other than their bearers. 5. Agencies, units, organizations or labor users shall have to receive medical insurance cards issued by social insurance agencies for timely hand-over to the subjects under their respective management. In case of loss of medical insurance cards, such must be notified immediately to the social insurance agencies that have issued the cards for re-issuance if plausible reasons are stated. 6. Vietnam Social Insurance shall guide in detail the issuance of medical insurance cards to the subjects, ensuring promptness, convenience and accuracy. PART II SCOPE OF BENEFITS OF MEDICAL INSURANCE CARD BEARERS I. BENEFITS OF MEDICAL INSURANCE CARD BEARERS 1. Bearers of valid compulsory medical insurance cards, when being medically examined and treated as outpatients or inpatients at public or non-public MET establishments which sign contracts on providing MET to medical insurance card bearers with social insurance agencies (hereinafter referred to as MET establishments engaged in medical insurance for short) shall be entitled to: a/ Medical examination, diagnosis, treatment and functional rehabilitation (according to the list promulgated by the Ministry of Health) during the treatment period at such MET establishments; b/ Medical test, image diagnosis and functional probe; c/ Medicines and transfusion fluids on the list promulgated by the Ministry of Health; d/ Blood and blood preparations; e/ Surgeries and operations; f/ Pregnancy checks and childbirth; g/ Access to medical supplies and equipment and patient beds; h/ Transportation costs in case of transfer to professionally and technically higher levels according to the Health Ministry's regulations applicable to the poor, social policy beneficiaries (defined in Clauses 6, 7, 10, 11 and 12, Section I, Part I of this Circular), people residing or working in region I, II or III according to region definition by the Ethnicity Committee on the basis of the criteria specified in Circular No. 41/UB-TT of January 8, 1996, of the Committee for Ethnicities and Mountainous Areas (now the Ethnicity Committee). 2. Compulsory medical insurance card bearers, when having MET at originally registered MET establishments or other MET establishments engaged in medical insurance at the recommendation for transfer to hospitals of a suitable professional and technical level according to the Health Ministry's regulations, or in cases of emergency at MET establishments engaged in medical insurance, shall have their MET expenses paid by social insurance agencies at the current hospital charge rates set by the State. 3. For medical insurance card bearers, when using expensive hi-tech services: 3.1. They shall have 100% of hi-tech service expenses of under VND 7,000,000 (seven million) paid by the Medical Insurance Fund. 3.2. For hi-tech service expenses of VND 7,000,000 (seven million) or more, payment shall be made as follows: a/ For subjects being revolution activists before August 1945, Vietnamese heroic mothers, war invalids, diseased soldiers, people enjoying policies like war invalids who have lost their working capacity by 81% or more, people aged 90 years or older, the Medical Insurance Fund shall pay 100% of service expenses for them. b/ For people with meritorious services to the revolution who are enjoying monthly allowances (except for the subjects defined at Item a above); resistance war activists and their blood children affected by toxic chemicals used by the US in the war in Vietnam, who are enjoying monthly allowances; helpless disabled elderly people; people enjoying monthly pensions and social insurance allowances and social policy beneficiaries enjoying monthly allowances; and people enjoying the MET entitlement for the poor, the Medical Insurance Fund shall pay 100% of service expenses for them, which, however, must not exceed VND 20,000,000 (twenty million) for each time of using such service. c/ For the remaining subjects, the Medical Insurance Fund shall pay 60% of expenses which, however, must not exceed VND 20,000,000 for each time of using such service, the remainder shall be paid by medically insured patients themselves to MET establishments. If 60% of the expenses is less than VND 7,000,000 (seven million), the Medical Insurance Fund shall pay an amount equal to VND 7,000,000 (seven million). Example: Medically insured patient Nguyen Van A used hi-tech services with a charge of VND 10,000,000. According to the provisions of this Point c, patient A shall be paid 60% x VND 10,000,000 = VND 6,000,000 by the Medical Insurance Fund. Since this amount is less than VND 7,000,000, patient A shall be paid an amount equal to VND 7,000,000 by the Medical Insurance Fund. The remaining amount of VND 3,000,000 shall be paid by patient A himself to the hospital. 3.3. The Ministry of Health shall promulgate a list of expensive hi-tech services after reaching agreement with the Ministry of Finance, which shall be used by social insurance agencies as a basis for making payment to MET establishments. 4. The costs of transportation of patients specified at Point h, Item 1, Section I, Part II of this Circular are paid as follows: a/ If patients are transported by means of transport of MET establishments, social insurance agencies shall pay transportation costs to the MET establishments with a norm not exceeding 0.2 liters of petrol/km (for return trip) at current prices at the time of transportation. If more than one patient is transported on the same means of transport, the payment norm shall be the same as for one patient. b/ If patients are not transported by means of transport of MET establishments, the MET establishments recommending patients to higher levels shall make payment for the patients with a norm of VND 30,000/100 km (for a single trip). 5. For compulsory medical insurance bearers who have MET at their personal requests: a/ If medical insurance card bearers have MET at proper professional and technical levels at their personal requests such as selecting doctors, patient's rooms and medical services by themselves, the Medical Insurance Fund shall pay the expenses at the State's current hospital charge rates applicable to such MET establishments. Patients shall themselves pay the difference between the charges of services provided at their requests and hospital charge rates set by the State. If medically insured patients request the use of services outside medical requirements, they shall pay by themselves for such services. b/ If medical insurance card bearers have MET at MET establishments with a professional and technical level higher than that stipulated by the Health Ministry, or have MET at MET establishments which do not sign contracts with social insurance agencies, the social insurance agencies shall pay the actual expenses, but the paid amount must not exceed the average expense for each type of MET at appropriate professional and technical level (according to the Appendix to this Circular). If they have MET in foreign countries, the social insurance agencies shall make payment at average charges of central-level hospitals in Hanoi and Ho Chi Minh cities. 6. For compulsory medical insurance card bearers, when having MET at originally registered MET establishments being non-public ones which sign contracts on MET under medical insurance, the social insurance agencies shall pay expenses at hospital charge rates of medical services at State-run MET establishments at appropriate professional and technical levels. Patients shall pay the MET establishments by themselves the difference (if any) between hospital charges set by non-public MET establishments and those agreed to pay by social insurance agencies. II. CASES WHICH SHALL NOT BENEFIT FROM MEDICAL INSURANCE Social insurance agencies shall not pay MET expenses in the following cases: 1. Treatment of leprosy; 2. Specific medicines for the treatment of tuberculosis, malaria, schizophrenia, epilepsy and other diseases, which have been covered by the state budget through national medical programs, projects or other funding sources; 3. Diagnosis and treatment of HIV/AIDS (excluding HIV tests according to medical requirements and subjects defined in the Prime Minister's Decision No. 265/2003/QD-TTg of December 16, 2003, on the regime for persons exposed to HIV or infected with HIV/AIDS due to occupational accidents or risks); gonorrhea and syphilis. 4. Vaccination, health recuperation, convalescence, early pregnancy tests and diagnosis, health checks, including regular health checks, health checks for recruitment of laborers, enrolment of students/pupils, military service, family planning services, and treatment of infertility; 5. Orthopedics and aesthetic plastics, making of artificial limbs, spurious eyes, dentures, optical glasses, hearing-aids; 6. Treatment of occupational diseases; labor accidents (accidents during working hours or at workplaces, including working overtime at labor users' requests; accidents outside workplaces while jobs are performed at labor users' requests; accidents on the way from homes to workplaces and vice versa); war casualties; accidents due to natural disasters; 7. Treatment in cases of suicide, intentionally inflicted injuries, drug addiction, or in cases of committing violations of law. 8. Medical expertise; forensic examination; psychiatric expertise; 9. Cases of MET, functional rehabilitation and birth delivery at home; 10. Use of assorted medicines outside the promulgated list, or medicines at patients' personal requests; use of medical treatment methods not yet permitted by the Health Ministry; cases of clinical research and test. PART III MANAGEMENT AND USE OF THE MEDICAL INSURANCE FUND I. MEDICAL INSURANCE FUND 1. The Medical Insurance Fund shall be formed from the following sources: a/ Medical insurance premiums paid by the state budget, labor users and medical insurance participants according to regulations; b/ State budget allocations at set levels for the purchase of medical insurance cards for subjects; c/ Revenues from financing and aid sources of organizations and individuals at home and abroad; d/ Other supports of the State and other lawful revenues (if any); e/ Profits generated from lawful measures taken to preserve and develop the Medical Insurance Fund. 2. The Medical Insurance Fund constitutes part of the Social Insurance Fund, is managed in a centralized, uniform, democratic and public manner in accordance with current financial management regulations applicable to Vietnam Social Insurance. The Medical Insurance Fund shall be used to pay MET and functional rehabilitation expenses for medical insurance participants within the scope of their benefits. Idle money (if any) of the compulsory Medical Insurance Fund shall be mobilized for application of measures to preserve and develop the Fund according to regulations. II. MANAGEMENT AND USE OF THE FUND 1. Management of the Medical Insurance Fund a/ Medical insurance payments (Points a and b, Item 1, Section I of Part III) shall be distributed and used as follows: - 95% shall be used for setting up of MET funds; - 5% shall be used for setting up of MET reserve funds. b/ The revenues mentioned at Points c and d, Item 1, Section I of Part III (if any) shall be accounted into MET funds. c/ The revenues mentioned at Point e, Item 1, Section I of Part III shall be accounted into MET reserve funds after the management expenses are deducted according to current financial management regulations applicable to Vietnam Social Insurance. d/ The MET funds not paid up annually shall be transferred to MET reserve funds. e/ If MET expenses in the year are beyond the MET funds' solvency, MET reserve funds shall be used as an addition thereto. If reserve funds have been used up, advance may be made from other unused funds of the Social Insurance Fund to make the set payments in full and in time according to current financial management regulations applicable to Vietnam Social Insurance. After annual financial settlement reports are approved, Vietnam Social Insurance's Management Board shall coordinate with the Ministry of Health and the Ministry of Finance in reporting and submitting to the Prime Minister a plan on refund of social insurance funds. 2. Use of MET funds Funds for MET under medical insurance shall be used to cover expenses for MET of outpatients and inpatients at originally registered MET establishments and MET expenses of medical insurance card bearers subject to hospital transfer or having MET at their personal requests, and transportation costs. 3. Balancing and regulating MET funds a/ Biannually and annually, provincial-level social insurance agencies shall sum up the use of MET funds by MET establishments in their respective localities. If MET funds are deficient, such must be reported to Vietnam Social Insurance for settlement. b/ Within the Medical Insurance Fund amounts permitted for use, Vietnam Social Insurance shall regulate MET funds, ensuring funds for provincial/municipal social insurance agencies to pay MET expenses covered by medical insurance to MET establishments. PART IV MET AND PAYMENT OF EXPENSES FOR MET COVERED BY MEDICAL INSURANCE I. MET COVERED BY MEDICAL INSURANCE 1. MET establishments engaged in medical insurance a/ Public MET establishments, which fully meet the set professional and technical criteria, may provide MET to medical insurance card bearers, including commune/war/township health stations (hereinafter referred collectively to as commune health stations), health stations (or clinics) of agencies and enterprises; regional polyclinics; maternity homes; hospitals and clinics having patient beds. b/ Non-public medical establishments, including polyclinics, specialized clinics, maternity homes and hospitals, may sign contracts on MET under medical insurance if fully meeting the legal conditions and accepting expense levels and payment mechanisms as those applicable to public MET establishments. 2. Selection and registration of primary MET establishments and transfer to higher-level MET establishments a/ Medical insurance card bearers may select one of primary MET establishments which are convenient and close to their places of residence or workplaces under the guidance of social insurance agencies for management and MET. Primary MET establishments shall be inscribed in medical insurance cards. b/ Medical insurance card bearers may request social insurance agencies to change originally registered MET establishments at the end of each quarter. c/ For branches and occupations of particular nature, where medical insurance card bearers have to regularly move or work itinerantly in different localities, social insurance agencies shall have to coordinate with agencies managing laborers and MET establishments in the localities in stipulating MET establishments and modes of payment of MET expenses, ensuring the benefits of medical insurance card bearers. d/ For maternity services: Medical insurance card bearers shall register pregnancy examination and management and childbirth at health stations, polyclinics or maternity homes; hospitals of rural/urban districts, provincial towns or cities; or provincial/municipal hospitals. e/ When medical insurance card bearers' ailments go beyond the technical and professional capabilities of MET establishments, patients shall be transferred to higher healthcare levels for treatment according to the Health Ministry's regulations. f/ In case of emergency, medical insurance card bearers may have MET at any MET establishments engaged in medical insurance in the Vietnamese territory (including public and non-public MET establishments) and fully enjoy medical insurance regimes. 3. Necessary procedures for MET covered by medical insurance a/ When having MET at an originally registered MET establishment, a medical insurance card bearer must produce his/her valid medical insurance card and another personal paper affixed with photo. b/ In case of re-examination at the doctor's appointment, the medical insurance card bearer must produce papers specified at Point a above and the hospital-discharge paper with re-examination appointment or re-examination appointment paper of the MET establishment (or stated in the health book) according to the Health Ministry's regulations applicable to hospitals. c/ In case of hospital transfer: the medical insurance card bearer must produce the papers specified at Point a above and hospital transfer dossiers according to regulations (including the hospital transfer recommendation and patient's brief records made by the MET establishment where the patient was given treatment). d/ The patient must immediately produce his/her medical insurance card and necessary papers listed above when having MET. If producing the card late, he/she shall enjoy medical insurance benefits only after producing the card. The patient must pay MET expenses by themselves to MET establishments for the days before he/she produces the card and shall have such expenses paid by social insurance agencies as for cases of MET at personal requests. In cases of emergency or coma without accompanying relatives, the patient must produce his/her medical insurance card before being discharged from the hospital for enjoyment of medical insurance benefits. 4. MET for medically insured patients MET establishments engaged in medical insurance shall have to provide MET to medical insurance card bearers under contracts signed with social insurance agencies in order to ensure the benefits of medical insurance participants, specifically: a/ To receive and guide medical insurance card bearers when they come for MET. b/ To examine and manage medical insurance cards and hospital transfer papers (in case of hospital transfer) right after the patients come for MET. In the period of hospitalizing medical insurance card bearers as inpatients, MET establishments shall manage the patients’ cards and return the cards to them when they are discharged from the hospital or transferred to higher-level hospitals. c/ For cases going beyond their professional capabilities, MET establishments shall have to transfer patients to higher-level hospitals strictly according to the Health Ministry's regulations on professional and technical levels and on procedures for hospital transfer. d/ MET establishments shall provide MET to patients, indicate tests, image diagnosis, functional probe and necessary professional techniques, ensuring rationality and safety strictly according to regulations. e/ To indicate the use of medicines and supply of medicines to both inpatients and outpatients according to the list of medicines promulgated by the Health Ministry, not to make prescriptions for patients to buy medicines by themselves. If prescriptions are made at patients' requests, "Prescriptions made at patients' requests" must be clearly stated to serve as a basis for medical insurance payment. f/ MET establishments, based on their professional and technical capabilities, shall have to ensure the adequate supply of medicines, blood, transfusion fluids, chemicals, medical supplies, etc. in service of MET and favorable conditions for patients and the payment between MET establishments and social insurance agencies. g/ When receiving patients transferred from other places, if deeming that they need not to be hospitalized as inpatients, the MET establishments (which receive the patients) shall have to supply medicines for treatment thereof as outpatients or give treatment indications and transfer the patients to appropriate professional and technical levels, not to make prescriptions for patients to buy medicines by themselves. h/ To coordinate with social insurance officials at MET establishments in explaining the medical insurance regimes and settle complaints related to the benefits of medical insurance card bearers. i/ To strictly make statistics of expenses for medical services used by medically insured patients, fully and accurately write relevant information in the course of MET for use as a basis for settlement with social insurance agencies. k/ Provincial/municipal Health Services and medical agencies of other ministries or branches shall have to direct MET establishments under their respective management to provide MET under medical insurance strictly according to regulations, and professionally manage them to ensure the efficient, rational and safe professional indications in providing MET; and at the same time, settle according to their competence violations committed by their attached MET establishments in providing MET to medical insurance card bearers. II. FORMS OF PAYMENT OF EXPENSES FOR MET COVERED BY MEDICAL INSURANCE 1. Payment between social insurance agencies and MET establishments Social insurance agencies shall pay MET expenses to MET establishments on the basis of contracts on MET under medical insurance for cases of MET at proper professional and technical levels or in cases of emergency, in form of payment based on service charges or on fixed amount. MET establishments shall select appropriate payment forms to enter into contracts with social insurance agencies. 1.1. Payment based on service charges a/ Payment principles and contents: - Payment based on service charge means a form of payment based on expenses for medical services used by medically insured patients. Expenses for medicines, medical supplies and transfusion fluids shall be paid at purchase prices of MET establishments; expenses for blood and blood preparations shall be paid at set prices. Expenses for other medical services shall comply with hospital charge rates applicable to MET establishments, approved by competent authorities, according to regulations on collection of hospital charges. - MET charge rates at commune health stations shall be provisionally set by presidents of provincial/municipal People's Committees, based on the hospital charge brackets applicable to district-level hospitals, jointly set by the Ministry of Health and the Ministry of Finance. - For non-public MET establishments signing contracts on MET under medical insurance, the charge rates of public establishments of equivalent professional level shall apply. b/ Modes of payment: - For MET establishments engaged in medical insurance (where medical insurance card bearers make original registration for MET) which provide MET to inpatients and outpatients: MET establishments may use 90% of MET funds (calculated on the total number of registered cards at the average medical insurance charges set by provinces or centrally-run cities) to cover the expenses for MET of outpatients and inpatients and transportation costs for medical insurance card bearers registering MET at such establishments and MET expenses at other establishments in cases of hospital transfer, emergency or having MET at patients' personal requests. - For MET establishments engaged in medical insurance (where medical insurance card bearers make original registration for MET) which provide MET to outpatients only: MET establishments may use 45% of MET funds calculated on the total number of registered cards at the average medical insurance charges set by provinces or centrally-run cities to cover the expenses for MET of outpatients at the registered MET establishments; expenses for MET of outpatients at other MET establishments in cases of hospital transfer, emergency or MET at patients' personal requests and transportation costs in case of hospital transfer. Social insurance agencies shall use the remaining MET fund amounts to pay for expenses for MET of inpatients at other MET establishments where the inpatients are hospitalized. - For commune health stations: Social insurance agencies shall sign contracts with district general hospitals (or MET establishments assigned by provincial/municipal Health Services the task of providing MET to people in rural/urban districts and provincial towns or cities in case of non-existence of district hospitals) to provide MET to medical insurance card bearers making original registration for MET at commune health stations. - Within the assigned funds for MET under medical insurance, district hospitals (or designated MET establishments) shall have to purchase medicines and medical supplies for commune health stations and pay for technical services provided by commune health stations according to regulations. - Social insurance agencies shall pay MET expenses for medical insurance card bearers at other MET establishments engaged in medical insurance and make corresponding deduction into funding sources for MET under medical insurance of MET establishments where medical insurance card bearers make original registration for MET. - If expenses for MET under medical insurance, including MET expenses at other MET establishments, exceed MET fund sources permitted for use, MET establishments shall be offset by social insurance agencies from 10% of the remaining MET funds of establishments providing MET to outpatients and inpatients or from 5% of establishments providing MET to outpatients only. - In cases where offsetting has been made but the funds still remain inadequate because there are few cards of original registration for MET, many people get serious or chronic diseases requiring big MET expenses or patients of MET establishments are of special nature, social insurance agencies shall have to balance the Medical Insurance Fund in order to timely pay for the excessive expenses, ensuring the benefits of patients and MET establishments. - Social insurance agencies shall have to make advance payments to MET establishments with a minimum amount equal to 80% of the settled MET amounts of the previous quarter; when making settlement, the two sides shall balance offsettings and social insurance agencies shall make further advance payments for the subsequent quarter. By the year-end, in November, social insurance agencies shall have to advance funds for MET establishments to buy medicines and medical supplies in service of patients in the subsequent year. 1.2. Payment based on fixed amount a/ Principles - Payment based on fixed amount means a payment form whereby social insurance agencies make payment with MET establishments, based on package amount (or fixed package amount) calculated for each medical insurance card bearer (or medical insurance card) registered at MET establishments within a definite time period (one year). - The total package fund in a year must not exceed the total fund used for MET for medical insurance card bearers, specifically: must not exceed 90% of the medical insurance MET funds, establishments providing MET to outpatients and inpatients, and 45% for establishments providing MET to outpatients only. Social insurance agencies shall use the remaining fund amounts to regulate and adjust the package amount, when necessary. - On the basis of the total determined package fund, social insurance agencies shall have to advance funds for MET establishments and make settlement. - MET establishments shall have to provide MET to medical insurance card bearers making registration within agreed duration without collecting any additional amounts from the benefits of medical insurance card bearers according to regulations. - MET establishments must cover all MET expenses according to the medical insurance regime for medical insurance card bearers registering MET at such establishments, including MET expenses for such people at other levels. - MET establishments shall use this package fund only for covering MET expenses and raising the quality of MET under medical insurance, but not for other purposes. - If the actual MET expenses are larger than the package fund due to such objective reasons as epidemics, increased chronic diseases, etc., social insurance agencies shall consider and pay the deficits. - The fixed package amount shall be properly adjusted in case of fluctuation in medical expenses, medical insurance premium levels, particularity in ailment structure of medical insurance card bearers making registration at each MET establishment. b/ Modes - Determination of package amount: The total fund (C) paid by social insurance agencies to MET establishments is determined as follows: C = M x N x k Of which: · M is the fixed package amount calculated on each medical insurance card · N is the total number of medical insurance cards registered for MET at such establishment in the year. · k is the adjustment coefficient due to fluctuation in MET expenses between the subsequent year and the previous year. Temporarily applicable coefficient k is 1.1. In case of sudden rises in MET expenses, the Ministry of Health and the Ministry of Finance shall adjust coefficient k. - Calculation of the fixed package amount (M): The average fixed package amount for a card is determined as follows: M = M1 + M2 + M3 Of which: · M1 is the average expense for MET of outpatients/card/year; · M2 is the average expense for MET of inpatients/card/year; · M3 is the average transportation freight/card/year. - The average expense shall be calculated on the basis of the previous year's expense. 2. Direct payment between social insurance agencies and medical insurance participants a/ Social insurance agencies shall make direct payment with medical insurance card bearers in the following cases: - Having MET at medical establishments at a professional and technical level higher than that stipulated by the Health Ministry; - Having MET at MET establishments which do not sign contracts with social insurance agencies; - Having MET in foreign countries. b/ For cases defined at Point a of Item 2 above, patients shall themselves pay MET expenses to MET establishments, and at the same time, keep all valid documents (prescriptions, medical record books, medicine invoices, hospital discharge papers, hospital charge receipts under the Finance Ministry's regulations, and other relevant documents) for use as bases to request the medical insurance agencies to refund part of MET expenses according to the provisions of Point b, Item 5, Section I, Part II of this Circular. 3. Other modes of payment Social insurance agencies and MET establishments shall study and propose other modes of payment such as payment according to diagnosis or average number of days of treatment of inpatients, etc. on the basis of ensuring the interests of medically insured patients as well as the interests of MET establishments and the safety of the Medical Insurance Fund in order to submit them to Vietnam Social for consideration and report to the Ministry of Health and the Ministry of Finance for decision. 4. Funds paid by social insurance agencies to MET establishments engaged in medical insurance come from units' revenues from hospital charges, which are managed and used according to the State's current regulations. PART V RIGHTS AND RESPONSIBILITIES OF SOCIAL INSURANCE AGENCIES AND MET ESTABLISHMENTS I. FOR SOCIAL INSURANCE AGENCIES 1. To issue in time medical insurance cards to the proper subjects. 2. To guide medical insurance card bearers in selecting convenient establishments for primary MET registration. 3. To sign, and coordinate in implementing, contracts with lawful MET establishments on providing MET to medical insurance card bearers. 4. To provide forms and documents guiding MET establishments to record and make statistics on MET expenses of medical insurance card bearers. To provide relevant data such as serial numbers of medical insurance cards of original registration for MET, average medical insurance premiums set by provinces or cities for determination of medical insurance MET funds of MET establishments. 5. To coordinate with MET establishments in examining papers to be produced by medical insurance card bearers when coming for MET and settle complaints related to the interests of medical insurance card bearers coming for MET. 6. To be provided by MET establishments with dossiers, patients' records and documents related to MET and pay MET expenses of patients for assessment and inspection, ensuring the interests of medical insurance card bearers and serving as a basis for making payment with MET establishments. 7. To refuse to pay MET expenses which are contrary to the provisions of the Medical Insurance Regulation and this Circular or the terms of medical insurance MET contracts signed between social insurance agencies and MET establishments; detect cases of abusing medical insurance cards or the Medical Insurance Fund and settle them according to their competence. 8. To make advance payments and settlement of MET expenses of medical insurance card bearers in time for MET establishments strictly according to regulations. To guide and make direct payment in time to medical insurance card bearers at social insurance agencies strictly according to regulations. 9. Provincial-level social insurance agencies shall quarterly (or after each settlement period) assume the prime responsibility for, and coordinate with provincial/municipal Health Services in, summing up and evaluating the use of MET funds in their respective localities and the assurance of the interests of medical insurance card bearers upon MET at MET establishments in provinces or cities for reporting to Vietnam Social Insurance and the Health Ministry for consideration and solution. 10. Social insurance agencies shall coordinate with mass media agencies in stepping up the medical insurance information, propagation and dissemination in various forms. II. FOR MET ESTABLISHMENTS ENGAGED IN MEDICAL INSURANCE 1. To indicate the use of medicines, transfusion fluids, blood and blood preparations, bio-products and supplies, the performance of operations, surgeries, tests and provision of medical services in a safe and reasonable manner according to the professional regulations of the Health Ministry. To strictly observe the regulations on hospital transfer. 2. To create favorable conditions for social insurance officials at the establishments to propagate and explain the medical insurance, guide medical insurance participants about their interests and responsibilities, and settle complaints related to MET of medical insurance card bearers. 3. To organize and monitor activities related to MET of medical insurance card bearers; make statistics on, and collect hospital charges paid by medical insurance card bearers themselves, issue hospital charge receipts to patients according to the Finance Ministry's regulations. 4. To fully, accurately and truthfully sum up MET expenses of medical insurance card bearers for timely making payment with social insurance agencies. PART VI ORGANIZATION OF IMPLEMENTATION 1. The Ministry of Health shall have to promulgate, amend or supplement lists of medicines, medical supplies, functional rehabilitation technical services and technical levels in MET to serve as a basis for payment of expenses for MET under medical insurance. 2. Vietnam Social Insurance shall have the responsibilities: a/ To direct, guide, inspect and evaluate the implementation of medical insurance policies nationwide in order to report and propose them to competent agencies for timely solution. b/ To inspect and supervise labor users' payment of medical insurance premiums strictly according to regulations, report thereon to competent agencies for settlement according to the provisions of law. c/ To draw up annual plans on medical insurance exploitation and send them to the Health Ministry and the Finance Ministry; implement legal provisions and satisfy competent agencies' requirements on statistical and reporting regimes on professional activities, financial statements as well as inspection and examination. 3. Provincial/municipal People's Committees shall have to direct, implement, examine and inspect the implementation of medical insurance regulations and settle problems arising in implementation of medical insurance policies in their respective localities. 4. Provincial/municipal Health Services shall instruct MET establishments in realizing policies to provide MET to medical insurance card bearers. 5. The Ministry of Defense, after reaching agreement with the Health Ministry and the Finance Ministry and on the basis of fully ensuring the interests and responsibilities under the Medical Insurance Regulation issued together with the Government's Decree No. 63/2005/ND-CP of May 16, 2005, shall guide the management and implementation of medical insurance by public employees, servants and defense workers working in army agencies, units and enterprises as well as contractual laborers working in military administrative units and army enterprises situated in strategic areas. PART VII IMPLEMENTATION PROVISIONS This Circular takes effect 15 days after its publication in "CONG BAO." All previous regulations, which are contrary to those in this Circular, are hereby annulled. Any problems arising in the course of implementation should be reported to the Health Ministry and the Finance Ministry for consideration and solution.