Medical care covered by health insurance.

1. Payment of medical care costs for those who receive improper-level medical care at district-level, provincial-level and central hospitals, and then appointed to inpatient treatment:

a) The health insurance fund shall pay according to the entitlement level specified in Clause 3 or 6, Article 22 of the Law on Health Insurance for the expenses for which the insured is appointed by the hospital to be admitted to the hospital for inpatient treatment, including medical examination and treatment services (pre-medical examination, subclinical tests, functional exploration, imaging, etc.) appointed or performed at the Department of Examination, Department of Emergency;

b) The health insurance fund shall not pay the costs of the outpatient medical care in case the insured has finished outpatient care and is then assigned to inpatient or inpatient day treatment with the same diagnose.

2. Payment of medical care costs in cases where the insured participates in improper-level medical care and is assigned for inpatient day treatment:

a) The health insurance fund shall pay the cost of daytime inpatient care for cases where the insured participates in medical care at the improper level at central or provincial-level hospitals and is appointed for inpatient daytime treatment in accordance with the Circular No. 01/2017/TT-BYT dated March 6, 2017 of the Minister of Health on chemotherapy, radiotherapy and chemotherapy combined with daytime radiation therapy at medical facilities and Circular No. 01/2019/TT-BYT dated March 1, 2019 of the Minister of Health on the implementation of inpatient day treatment in traditional medical facilities, as specified in Point a (for central hospitals) or Point b, Clause 3 and Clause 6, Article 22 of the Law on Health Insurance (for provincial-level hospitals).

b) If the insured person is appointed for inpatient day treatment by the hospital, it is determined as inpatient treatment and inpatient day treatment costs are paid the same to the case of inpatient treatment instructed in this dispatch.

3. The level of entitlement and encryption of data and recording of medical care costs in case the insured person register improper-level medical care according to the provisions of Point c, Clause 3, Clause 4 and Clause 6, Article 22 of the Law on Health Insurance:

a) For an insured who receives medical examination at district-level hospitals specified at Point c, Clause 3, Article 22 of the Law on Health Insurance and at provincial-level hospitals nationwide as prescribed in Clause 6, Article 22 of the Law on Health Insurance:

- In case a participant of health insurance receives medical care at district-level hospitals nationwide specified at Point c, Clause 3, Article 22 of the Law on Health Insurance: He/she will be covered by the health insurance fund with inpatient and outpatient medical care costs at the same entitlement level of primary medical care;

- In case a participant of health insurance receives medical care at provincial-level hospitals nationwide as prescribed in Clause 6, Article 22 of the Law on Health Insurance: He/she will be covered by the health insurance fund with inpatient medical care costs at the same rate of entitlement to primary medical care;

- A participant of health insurance who receives medical care at the improper level as specified at Point a of this Section will not be entitled to the non-co-payment of medical care costs as specified at Point c, Clause 1, Article 22 of the Law on Health Insurance; the share of the patient's co-payment cost in case of receiving improper-level medical care is not identified as a condition for the social insurance agency to issue the Certificate of not having the costs paid in the year.

- The medical establishments will encode and record the case of receiving improper-level medical care specified at Point a, Section 1 of this dispatch as follows:

+ Select number "3" to write in Field 16 (MA_LYDO_VVIEN) of Table 1 attached to Decision No. 4210/QD-BYT dated September 20, 2017 of the Minister of Health on providing for output data standards and formats used in management, assessment and payment for medical services covered by health insurance fund;

+ Enter the entitlement level of 80 or 95 or 100 corresponding to the benefit code on the health insurance card at field 17 (MUC_HUONG) of Table 2, Table 3 promulgated with Decision No. 4210/QD-BYT;

+ Select "Improper Level" in Section 14, Part I (Administration) of the Medical examination and treatment list attached to Decision 6556/QD-BYT dated October 30, 2018 of the Minister of Health on promulgating forms of a list of medical service costs used at medical establishments.

+ Enter the entitlement level of 80 or 95 or 100 corresponding to the entitlement level stated on the health insurance card in the section Entitlement Level Part II (Medical examination and treatment costs) of the List of medical examination and treatment costs attached to Decision 6556/QD -BYT.

b) If the insured person registers for initial medical care at a commune health station or a polyclinic or a district-level hospital receives medical care at a commune health station or a polyclinic or a district-level hospital in the same province as specified in Clause 4, Article 22 of the Law on Health Insurance, the case is defined as primary medical care and the term "inter-level" to serve the statistical work and reporting:

- To be covered with inpatient medical care costs by the health insurance fund according to the entitlement level of primary medical care;

- To enjoy the regime of non-co-payment of medical care costs as prescribed at Point c, Clause 1, Article 22 of the Law on Health Insurance; In this case, the patient's share of cost co-payment is determined to be eligible for the social insurance agency to issue a Certificate of not having the costs paid in the year.

- The medical establishments shall encode and record as follows:

+ Select number "4" to write in Field 16 (MA_LYDO_VVIEN) of Table 1 attached to Decision No. 4210/QD-BYT;

+ Enter the entitlement level of 80 or 95 or 100 corresponding to the code of entitlement level on the health insurance card at field 17 (MUC_HUONG) of Table 2, Table 3 promulgated with Decision No. 4210/QD-BYT;

+ Select "Inter-level" in Section 13, Part I (Administration) of the List of medical examination and treatment costs attached to Decision 6556/QD-BYT.

+ Enter the entitlement level of 80 or 95 or 100 corresponding to the the code of entitlement level stated on the health insurance card in the section Entitlement Level Part II (Medical examination and treatment costs) of the List of medical examination and treatment costs attached to Decision 6556/QD -BYT.

c) In case the participant of health insurance receives medical care at improper level is under inpatient treatment but the health insurance card has expired:

- In case the health insurance card has not been renewed or the expiry date of the new health insurance card does not follow the expiration date of the old health insurance card: The health insurance fund shall pay the medical care costs according to the scope and level of entitlement of the old health insurance card until discharge or until the day immediately preceding the date the new health insurance card becomes valid without exceeding 15 (fifteen) days as prescribed in Clause 9, Article 27 of the Government's Decree No. 146/2018/ND-CP dated October 17, 2018 elaborating and providing guidance on measures to implement certain articles of law on health insurance;

- In case a newly issued health insurance card has a change in the entitlement level, arising expenses from the date the new health insurance card becomes valid will be charged according to the new rate.

For example: The participant of health insurance with the health insurance card code CN3 (the benefit rate of 95%), enters the hospital for inpatient treatment from December 15, 2020 and the health insurance card CN3 expires on December 31 In 2020, then he/she will participate in household-based health insurance and has a new card code GD4 (the benefit rate of 80%) with a expiry date from January 6, 2021. He/she is discharged at January 20, 2021 and the medical care costs are covered by the health insurance fund as follows:

+ The cost of medical examination and treatment within the scope of health insurance benefits arising from December 15, 2020 until the end of December 31, 2020: is covered by the health insurance fund at the rate of 60% multiplied by the rate of entitlement of 95% (the rate under the health insurance card code is CN3);

+ Medical care costs within the scope of health insurance benefits arising from January 1, 2021 until the end of January 5, 2021: 95% of the cost is covered by the health insurance fund (the rate under the health insurance card code is CN3);

+ Medical care costs within the scope of health insurance benefits arising from January 6, 2021 until January 20, 2021: 80% of the costs will be covered by the health insurance fund (the rate under the health insurance card code is GD4).

4. To ensure the rational and efficient use of the health care fund of health insurance; to enhance the responsibility of medical establishments and participants of health insurance as well as ensuring the benefits of participants of health insurance, the Ministry of Health shall:

a) Request Heads of units to assume the prime responsibility for, and coordinate with the social insurance body of provinces, cities and relevant agencies and units:

- To regularly remind officials, employees and employees under their management to strictly comply with the provisions of the law on medical examination and health insurance, Directive No. 10/CT-BYT dated September 9, 2019 of the Minister of Health on strengthening prevention and control of abuse and profiting from the health insurance fund, Directive No. 25/CT-BYT dated December 21, 2020 of the Minister of Health on further strengthening management and improving quality of medical services covered by health insurance.

- To strictly comply with provisions in Article 2 of Decision No. 6556/QD-BYT: “During a medical examination or a treatment course for each patient, a medical establishment is responsible for creating 1 (one) List of medical examination and treatment costs and keep it with the patient's medical record and 1 (one) List to provide to the patient”.

b) To periodically or unexpectedly have the Ministry of Health coordinate with relevant agencies and units to inspect the implementation of policies and laws on health insurance. Heads of medical establishments shall be responsible before the law and the Minister of Health if the units do not comply with the regulations.

5. The Ministry of Health requests the Vietnam Social Security to direct and guide the social insurance agencies of provinces and centrally-run cities to study and coordinate with the units in the locality to implement the guidance contents in this dispatch.

6. Contents guided in this dispatch are applicable from January 1, 2021. The units are requested to actively coordinate with the social insurance agency and relevant agencies and units regarding the implementation. May any difficulties and problems arise, please report to the Ministry of Health for timely consideration and settlement./.