Thông tư 35/2016/TT-BYT

CIRCULAR

ON PROMULGATING THE LIST OF MEDICAL SERVICES COVERED BY HEALTH INSURANCE, COINSURANCE PERCENTAGES AND COVERAGE THEREOF

Pursuant to the Government’s No. 63/2012/NĐ-CP dated August 31, 2012 on functions, duties, powers and organizational structure of the Ministry of Health;

Pursuant to Law on Health Insurance;

Pursuant to the Government’s Decree No. 105/2014/NĐ-CP dated 15, 2014 providing guidelines for certain articles of Law on Health Insurance;

Pursuant to the Government's Decree No. 70/2015/NĐ-CP dated September 01, 2015 providing guidelines for certain articles of Law on Health Insurance for People’s Army, People’s Public Security and cipher officials;

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

The Minister of Health promulgates the Circular on the list of medical services covered by health insurance, coinsurance percentages and coverage thereof.

Article 1. Lists of medical services covered by health insurance

1. Lists of medical services covered by health insurance contain services related to medical examination and treatment, rehabilitation, regular prenatal check-ups and childbirth that are allowed to be provided in Vietnam by the Minister of Health (except for the medical services prescribed in Article 23 of Law on Health Insurance) and include:

a) The lists of technical qualifications related to medical examination and treatment issued together with the Circular No. 43/2013/TT-BYT promulgated by the Minister of Health;

b) The lists of classification of surgery and procedures issued together with the Circular No.50/2014/TT-BYT promulgated by the Minister of Health;

c) Medical services that have been approved to be provided in medical facilities by the Minister of Health but have not been prescribed in the Circular No. 43/2013/TT-BYT or the Circular No.50/2014/TT-BYT

2. Lists of certain medical services with the specific coverage, coinsurance percentages or payout limits issued together with this Circular include:

a) The list No.1 including medical services with specific coverage, coinsurance percentages and payout limits;

b) The list No.2 including medical services with specific coverage;

c) The list No.3 including medical services not covered by health insurance.

Article 2. Coinsurance percentage

1. Coinsurance percentage is the percentage of the price for the medical service covered by health insurance.

a) Regarding a medical service with specific coverage prescribed in Column 4 of the list No.1 issued together with this Circular, the coinsurance percentage will be the rate of price for this medical service.

b) Regarding a medical service whose payment price is determined according to the price for another medical service prescribed in Column 4 of the list No.1 issued together with this Circular, the coinsurance percentage will be 100% of the price for the service prescribed in the Column 4.

c) 100% of the prices for the medical services other than those mentioned in Point a and Point b Clause 1 of this Article shall be covered by health insurance.

2. If the price for a medical service includes costs of medicines and medical materials, its coinsurance percentage shall comply with regulations of this Circular and the coinsurance percentage of medicines or medical materials is not required to be determined.

3. Regarding medical services whose prices exclude costs of medicines and medical materials

a) Coinsurance percentages of these medical services shall be applied in accordance with this Circular.

b) Coinsurance percentages of costs of medicines and medical materials shall be applied in accordance with regulations of the Circular on promulgating the list of medicines and medical materials covered by health insurance.

Article 3. Payout conditions

1. The health insurance fund will cover costs of the medical services prescribed in Clause 1 Article 1 of this Circular if:

a) These services are approved to be provided in medical facilities by a competent authority;

b) These services are provided in accordance with the professional procedures approved by the competent authority; and

c) Prices for medical examination and treatment under health insurance are approved by a competent authority;

2. The health insurance will only cover the medical services prescribed in Point s Clause 2 Article 1 (the list No.1) and Point b Clause 2 Article 1 (the list No.2) issued together with this Circular if the conditions prescribed in Points a, b and c Clause 1 of this Article and the payout conditions prescribed in Column 3 of the list No.1 and Column 3 of the list No.2 are satisfied.

Article 4. Instructions on payment by health insurance

1. Payment principles

a) The health insurance fund shall cover medical expenses within the payout limits and prices for medical examination and treatment services covered by health insurance prescribed in Articles 21, 22 and 31 of Law on Health Insurance and in accordance with the health insurance coverage, coinsurance percentage and payout limits prescribed in this Circular.

b) A patient shall pay costs not covered by health insurance.

2. Regarding medical services whose coinsurance percentages are specified in the list No. 1 issued together with this Circular.

a) The health insurance fund shall cover a cost equal to the price for the medical service multiplied by (x) the coinsurance percentage prescribed in Column 4 of the list 1 issued together with this Circular.

b) A patient shall make co-payment (if any) equal to price for the medical services multiplied by (x) the rate of co-payment multiplied by (x) the coinsurance percentage prescribed in Column 4 of the list No. 1 issued together with this Circular and cover self-pay costs equal to price for the medical service multiplied by the rate of self-payment prescribed in Column 4 of the list No. 1 issued together with this Circular.

3. Regarding a medical service for which payment is made according to the price for other medical services prescribed in the list No.1 issued together with this Circular.

a) The health insurance fund shall cover the cost equal to price for the medical service prescribed in Column 4 of the list No. 1 multiplied by the coinsurance percentage.

b) A patient shall make co-payment (if any) calculated according to price for the medical services prescribed in Column 4 of the list No. 1 and is not required to pay the difference between the price for provided medical service and those of the medical service prescribed in column 4 of the list 1 issued together with this Circular.

Example: A patient is entitled to 95% coverage by health insurance and the emergency dialysis service prescribed is covered. The price for the emergency dialysis service is equal to the price for the artificial kidney service, which is 1,515,000 VND.

If the patient has not undergone Arteriovenous fistula (AVF) surgery or has undergone AVF surgery but has not used it, he/she will make payment according to the price for the “emergency artificial kidney” service. To be specific:

- The cost covered by the health insurance fund is 1,439,250 VND (1,515,000 VND x 95%)

- The cost paid by the patient is 75,750 VND (1,515,000 VND x 5%)

If the patient has undergone AVF surgery and the AVF is usable, he/she will make payment according to the price for the “regular artificial kidney” service, which is 543,000 VND

- The cost covered by the health insurance fund is 515,850 VND (543,000 VND x 95%)

- The cost paid by the patient is 27,150 VND (543,000 VND x 5%)

- The patient is not required to pay the difference, which is 972,000 VND (1,515,000 VND - 543,000 VND).

4. The health insurance fund will not cover costs of a medical service if:

a) The medical service is included in professional procedures of another medical service whose price includes costs of this service;

b) The medical service has its results determined from the results of another medical service or from the provision of another medical service.

5. Regarding medical services that are the new techniques or new measures prescribed in Clauses 1 and 2 Article 69 of Law on medical examination and treatment and have their prices determined from the day on which this Circular comes into force, the health insurance fund shall make payment if their coverage and coinsurance percentages specified by the Minister of Health.

6. The health insurance fund will not cover the medical services prescribed in the list No. 3 issued together with this Circular.

Article 5. Transition clause

1. If a participant in health insurance uses services provided by a medical facility before this Circular comes into force and stop using these services from the day on which this Circular comes into force, the coverage, coinsurance percentages and payout limits prescribed in this Circular shall not be applied. The health insurance fund and participant shall pay costs of medical services in accordance with regulations in Clause 3 Article 20 of the Joint Circular No. 41/2014/TTLT-BYT-BTC of the Ministry of Health and Ministry of Finance dated November 24, 2014 on providing guidance on health insurance.

2. Regarding medical services whose payout conditions specifies that their providers shall obtain training diplomas but they have obtained training certificates instead of training diplomas, these providers may use their training certificates until December 31, 2017.

Article 6. Reference clause

If documents referred in this Circular are amended or superseded, new documents and amended documents will be applied.

Article 7. Effect

This Circular comes into force from December 01, 2016

Article 8. Implementation

1. The Ministry of Health shall take charge and cooperate with relevant authorities in making amendments to lists of medical services issued together with this Circular to ensure qualified medical services, effective treatment and conformity between the payment rate and coinsurance percentages and encourage the controllable development of use of medical services with reasonable costs.

2. The Vietnam Insurance Security shall organize the implementation and payment of medical expenses covered by health insurance in accordance with regulations of law on health insurance and this Circular.

3. Departments of Health, medical authorities affiliated to ministries shall direct their affiliated medical facilities to implement this Circular.

4. Medical facilities shall:

a) Prescribe and provide sufficient medical services to ensure rights and interests of participants in health insurance;

b) Provide patients, their parents, godparents or representatives with information and explanations related to the self-payment of the difference if they select medical services themselves;

c) Cooperate with the Vietnam Insurance Security in payment of costs of medical services in accordance with regulations of law on health insurance and this Circular.

Any problem arising during the implementation of this Circular should be reported to the Ministry of Health for consideration and solution.