Nghị định 58/1998/ND-CP

DECREE

PROMULGATING THE MEDICAL INSURANCE REGULATION

THE GOVERNMENT

Pursuant to the Law on Organization of the Government of September 30, 1992;
At the proposal of the Minister of Health,

DECREES:

Article 1.- To promulgate together with this Decree the Medical Insurance Regulation.

Article 2.- This Decree takes effect 45 days after its signing.

This Decree replaces Decree No. 299/HDBT of August 15, 1992 of the Council of Ministers (now the Government) promulgating the Medical Insurance Regulation and Decree No. 47-CP of June 6, 1994 of the Government amending a number of Articles of the Medical Insurance Regulation.

Article 3.- The Minister of Health, the Minister of Finance, the Minister of Labor, War Invalids and Social Affairs and the Minister-Head of the Government Commission on Organization and Personnel shall have to guide the implementation of this Decree.

Article 4.- The ministers, heads of the ministerial-level agencies, heads of the agencies attached to the Government and presidents of the People's Committees of the provinces and cities directly under the Central Government shall have to implement this Decree.

THE MEDICAL INSURANCE REGULATION

(Issued together with Decree No.58/1998/ND-CP of August 13, 1998 of the Government)

Chapter I

GENERAL PROVISIONS

Article 1.- Medical insurance (MI) stipulated in this Regulation constitutes a social policy the implementation of which is organized by the State with the aim of mobilizing the contributions from employers, employees, organizations and individuals to pay for the medical examination and treatment costs as prescribed in this Regulation for the bearers of MI cards when they are ill.

Article 2.- Compulsory medical insurance shall apply to the following subjects:

1. Vietnamese laborers working in:

a/ The State enterprises, including enterprises of the armed forces units;

b/ Economic organizations of non-business administrative agencies, offices of the Party or socio-political organizations;

c/ Foreign-invested enterprises, export processing zones and industrial parks; foreign agencies and organizations, international organizations based in Vietnam, except for cases otherwise provided for by international treaties which the Socialist Republic of Vietnam has signed or acceded to;

d/ Non-State economic units and organizations that employ 10 laborers or more each.

2. State officials and employees working in non-business administrative agencies; people working in the Party's bodies or socio-political organizations; commune, ward and township officials who enjoy monthly grants under the provisions of Decree No.09/1998/ND-CP of January 23, 1998 of the Government; and people working in elective bodies from the central to the commune/ward levels.

3. People who are enjoying the retirement regime and monthly social insurance allowances due to the decline of their working capacity.

4. People with meritorious services to the revolution as prescribed by law.

5. Subjects enjoying social support who are provided with allowances by the State through the social insurance.

Article 3.- Voluntary medical insurance shall apply to all subjects that have a demand to participate in the medical insurance.

Article 4.-

1. The MI fund shall be formulated from the MI premiums and other sources.

2. The MI fund shall be uniformly managed and used for the payment of medical examination and treatment costs as well as for the MI administrative management.

3. The MI activities shall be exempt from taxes.

Article 5.- Vietnam Medical Insurance shall be organized in a vertical system and subject to uniform management from the central level to the grassroots; be allocated fund by the State for the construction of material and technical bases; and be allowed to take measures to preserve and increase the MI fund in accordance with the provisions of law.

Chapter II

MEDICAL INSURANCE REGIME AND PAYMENT OF MI EXAMINATION AND TREATMENT COSTS

Article 6.- Bearers of compulsory HI cards shall be entitled to the HI regime for medical examination and treatment as well as hospitalization, including:

1. Medical examination, diagnosis and treatment;

2. Medical test, X-ray examination and photography and functional probe;

3. Medicines on the list promulgated by the Ministry of Health;

4. Blood, serum;

5. Instrumental and manual operations;

6. The access to medical appliances, equipment and patients' beds.

Article 7.- Medical examination and treatment costs under the MI regime shall be paid according to the following levels:

1. The MI fund shall cover 80% of medical examination and treatment costs according to the hospital fee levels while the remaining 20% shall be paid by the patients to the concerned medical establishments. As for social policy beneficiaries defined in the Ordinance on preferential treatment for revolutionaries, war dead and their families, war invalids and diseased armymen, people who have participated in resistance wars and people who have made meritorious contributions to the revolution, 100% of their medical examination and treatment costs shall be covered by the MI fund according to the hospital fee level;

2. If the sum of money paid for the 20% of medical examination and treatment costs by a patient himself/herself in a year already exceeds the amount of his/her six months' minimum wages, the medical examination and treatment costs arising in the remaining period of the year shall be fully paid by the MI fund.

Article 8.- Bearers of MI cards shall enjoy the MI regime according to the provisions of Article 7 of this Regulation only when:

1. Their medical examinations and treatments are carried out at the medical establishments already registered in their cards for health management and care;

2. Their medical examinations and treatments are carried out at other medical establishments at the recommendation of their registered medical establishments for the hospital transfer suited to medically professional lines as stipulated by the Ministry of Health;

3. They have their medical examinations and treatments at any State-owned medical establishments in case of emergency.

Article 9.- In cases where medical examinations and/or treatments are carried out at the patients' personal requests: selecting doctors, patient's rooms, medical establishments and medical services by themselves; having their medical examinations and/or treatments at medical establishments beyond the medically professional lines prescribed by the Ministry of Health; or having their medical examinations and/or treatments at medical establishments which do not sign contracts with the medical insurance agency, the MI fund shall only cover the medical examination and/or treatment costs at the hospital fee levels set for appropriate professional lines in accordance with the Ministry of Health's regulations and Article 7 of this Regulation. All differences (if any) shall be paid by the MI card bearers to the concerned medical establishments.

Article 10.- The MI fund shall not make payment in the following cases:

1. Treatment of leprosy; use of medicines for the treatment of tuberculosis, malaria, schizophrenia, epilepsy, and family-planning services (which are already funded by the State budget);

2. Prevention and treatment of rabies; HIV-AIDS, gonorrhea and syphilis prevention, tests, diagnosis and treatment;

3. Vaccination injection for disease prevention, sanatorium regime, health check and treatment of infertility;

4. Orthopedics and aesthetic plastics, making of artificial limbs, spurious eyes, dentures, glasses, hearing-aids, artificial lens, joints and heart valves;

5. Congenital diseases and deformities;

6. Occupational diseases; labor and traffic accidents, as well as casualties caused by wars or natural calamities;

7. Suicide, injuries intentionally caused to others, drug addiction and violation of law.

Article 11.- MI medical examination and treatment costs shall be paid in either one of the two following forms:

1. The MI agency makes payment to the medical establishments under contracts.

2. The MI agency pays medical examination and treatment costs to the medically insured patients according to the provisions of Articles 7 and 9 of this Regulation.

Chapter III

RESPONSIBILITIES, MODES AND LEVELS OF PAYMENT OF COMPULSORY MEDICAL INSURANCE PREMIUMS

Article 12.- Levels of payment and responsibility to pay compulsory MI premiums are stipulated as follows:

1. Subjects defined in Points a and b, Clause 1, Article 2 of this Regulation shall pay MI premiums at a level equal to 3% of their grade or rank, salaries, difference coefficient in reservations (if any) as stated in the labor contracts and territory, cost of living, position and working seniority allowances, of which 2% shall be paid by the employers and 1%- by the employees.

2. Subjects defined in Points c and d, Clause 1, Article 2 of this Regulation shall pay MI premiums at a level equal to 3% of their wages, pays and allowances (if any) as stated in the labor contracts and in accordance with the stipulations of the State, of which 2% shall be paid by the employers and 1%- by the employees.

3. Subjects defined in Clause 2, Article 2 of this Regulation:

a/ For wage earners: the MI premium level shall be equal to 3% of their grade or rank salaries, the difference coefficient in reservation (if any) and territory, cost of living, position and working seniority allowances in accordance with the stipulations of the State. Of this, 2% shall be paid by the employing agencies and 1%- by the officials and/or employees themselves.

b/ For monthly grant earners being cadres of the Party organizations, administrations, mass organizations and non-business agencies in communes, wards and townships: the MI premium level shall be equal to 3% of their monthly grants and allowances (if any). Of this, 2% shall be paid by the monthly grant providing agencies and 1%- by the grant earners.

c/ For monthly grant earners being incumbent deputies to the People's Councils of different levels, not on the State payroll or not entitled to the monthly medical insurance regime: the MI premium level shall be equal to 3% of the current minimum wage and paid by the monthly grant providing agencies.

4. For subjects defined in Clause 3, Article 2 of this Regulation the MI premium level shall be equal to 3% of their pensions or monthly social insurance allowances paid directly by the social insurance agency.

5. For subjects defined in Clauses 4 and 5, Article 2 of this Regulation, the MI premium level shall be equal to 3% of the current minimum wages paid directly by the agency that manages their wages.

6. The Ministry of Finance shall have to balance the budget estimates to effect the compulsory medical insurance regime for subjects defined in Points b and c, Clause 3, Article 12 of this Regulation from January 1st, 1999.

Article 13.- Modes of MI premium payment:

1. Employing agencies, units and individuals defined in Clauses 1, 2 and 3, Article 12 of this Regulation shall pay in advance the MI premiums, which shall be collected from the employees according to the prescribed levels, and remit them into the MI fund at least once every three months.

2. Agencies and units managing funds of subjects defined in Clauses 4 and 5, Article 12 of this Regulation shall remit the collected MI premiums into the MI fund once every three months.

3. Employing agencies, units and individuals and the MI agency may sign long-term contracts on the premium payment and MI card issuance.

Chapter IV

RIGHTS AND RESPONSIBILITIES OF PARTIES PARTICIPATING IN MEDICAL INSURANCE

Article 14.-

1. A MI-card bearer shall have the rights:

a/ To have his/her medical examination and treatment under the MI regime as prescribed in Chapter II of this Regulation;

b/ To choose one of the convenient primary healthcare establishments at his/her place of residence or work place under guidances of the MI agency for the management, health care and medical examination and treatment;

c/ To change his/her registered primary healthcare establishment at the end of every quarter;

d/ To have the hospital fees paid under the MI regime when giving birth to her first or second child;

e/ To request the MI agency to ensure his/her rights and interests in accordance with the provisions of this Regulation;

f/ To complain to the competent State agencies about the violations of this Regulation by employers, MI agencies or medical establishments.

2. A MI -card bearer shall have the responsibilities:

a/ To pay MI premiums in full amount and on time;

b/ To prevent the MI card to the medical establishment for medical examination and treatment;

c/ To preserve and not to let others borrow his/her MI card.

Article 15.-

1. Employing agencies, units and individuals shall have the rights:

a/ To refuse to meet the requirements of the MI agencies and/or medical establishments which are contrary to the provisions of this Regulation;

b/ To complain to the competent State agencies violations of the Medical Insurance Regulation by medical establishments. Pending the settlement, they shall still have to pay MI premiums in accordance with the provisions of this Regulation.

2. Employing agencies, units and individuals shall have the following responsibilities:

a/ To pay MI premiums in strict accordance with the provisions of the MI Regulation;

b/ To supply to the MI agencies with documents on labor, wages, pays and allowances related to the MI premium payment and the implementation of the MI regime;

c/ To submit to the inspection and supervision by the competent State agencies in the implementation of the MI regime.

Article 16.-

1. The MI agency shall have the rights:

a/ To request the employing agencies, units and individuals to pay MI premiums and implement the MI regime and to supply documents related to the MI premium payment and the implementation of the MI regime;

b/ To organize card-distribution agents;

c/ To sign contracts with lawful medical establishments for providing medical examination and/or treatment for the insured;

d/ To request medical establishments to supply dossiers, patients' records and documents related to the payment of examination and treatment cost under the MI regime;

e/ To refuse the payment of medical examination and treatment costs which are contrary to the provisions of the MI Regulation or to the terms of contracts signed between the MI agencies and medical establishments;

f/ To seize fake MI vouchers and cards so as to transfer them to the investigating agencies for handling according to law;

g/ To request the competent agencies to handle units and/or individuals that breach the MI Regulation.

2. The MI agency shall have the responsibilities:

a/ To collect MI premiums, issue MI cards and guide the management and use of MI cards;

b/ To provide information on medical establishments and guide the insured to select medical establishments for registration;

c/ To manage the MI fund and pay all MI costs according to regulations in time;

d/ To inspect and evaluate the implementation of the MI regime;

e/ To organize the dissemination of information on MI and propagate it;

f/ To settle complaints about the implementation of the MI regime according to its competence.

Article 17.-

1. A medical establishment shall have the rights:

a/ To request the MI agency to make advance payment of medical examination and treatment costs in accordance with the provisions of the MI Regulation and the signed contract on medical examination and treatment;

b/ To provide medical examinations and treatments as well as medical services in strict compliance with professional principles;

c/ To request the MI agency to supply data on HI cards which are registered at such medical establishment;

d/ To refuse to meet the requirment outside the MI Regulation and the contract signed with the MI agency;

e/ To litigate at the competent agencies when the MI agency breaches the contract on MI medical examinations and/or treatments.

2. A medical establishment shall have the responsibilities:

a/ To strictly comply with the contract on MI examinations and treatments;

b/ To record and supply documents related to the medical examinations and treatments for the insured, which shall serve as basis for the payment of costs and settlement of MI-related disputes;

c/ To prescribe medicines, biological objects, instrumental or manual operations, tests as well as safe and reasonable medical services according to the professional regulations of the Ministry of Health;

d/ To create favorable conditions for the MI agency's personnel based at the medical institution to conduct propaganda and explanation on MI; to inspect the assurance of MI-card bearers' rights and interests and settle their complaints about medical examinations and/or treatments;

e/ To check MI cards, detect and notify to the Vietnam Medical Insurance cases of violating and abusing the MI regime.

Chapter V

MANAGEMENT AND USE OF MI FUND AND CARDS

Article 18.- The MI fund shall be managed concentratedly and uniformly in the whole system of Vietnam Medical Insurance; subject to cost-accounting independent from the State budget and protected by the State.

Article 19.- MI premiums paid by the insured under the compulsory medical insurance shall be distributed and used as follows:

1. 91.5% are reserved for the medical examination and treatment fund, including 5% for the establishment of the reserve fund for medical examinations and treatments.

a/ The remainder of the medical examination and treatment fund, which is not fully used in a year shall be transferred into the reserve fund;

b/ In cases where the medical examination and treatment costs exceed the payment capability of the medical examination and treatment fund, addition shall be made thereto from the reserve fund.

2. 8.5% are reserved for regular spending on the management of the Vietnam Medical Insurance system according to the annual estimates ratified by the competent level and the State's regulations on spendings.

3. The MI fund's temporarily idle money (if any) shall be used to buy bills of credit and/or bonds issued by the State Treasury and State-owned commercial banks; and other measures may be applied in order to preserve and increase the MI fund, but the sources of payment, when necessary, must be ensured.

The Ministry of Health and the Ministry of Finance shall jointly issue a financial management regulation with regard to Vietnam Medical Insurance.

Article 20.-

1. MI cards shall be issued by Vietnam Medical Insurance.

2. MI cards may be used immediately and continuously when the MI premiums are paid according to stipulations.

3. A MI card may be used only after 30 days from the date the MI premiums are paid in the following cases where:

a/ The MI premiums are paid for the first time or

b/ The MI premium payment resumes after a period of interruption due to any causes.

Chapter VI

VOLUNTARY MEDICAL INSURANCE

Article 21.- The voluntary medical insurance is stipulated in this Regulation with the aim of realizing social policy on medical examinations and treatments not for the commercial purposes and not according to the provisions of the legislation on insurance business.

Article 22.- Voluntary medical insurance shall apply to all subjects in the society, including foreigners working, studying or making visits in Vietnam.

The Government encourages the expansion of voluntary MI and the diversification of their forms and at the same time encourages the Red Cross Society, charity societies, mass organizations, the State-run and private economic organizations to contribute to buying MI cards for the poor. The People's Committees of different levels shall have to care for and create favorable conditions for the local people to participate in the voluntary MI.

Article 23.-

1. Forms of voluntary MI shall include:

a/ Medical examination and treatment insurance for outpatients;

b/ Medical examination and treatment insurance for inpatients;

c/ MI regime being additional to the compulsory MI;

d/ Other forms of voluntary MI.

2. Bearers of voluntary MI cards shall have their medical examination and treatment costs covered by the MI fund according to the levels of voluntary MI premium payment and forms they have selected. If the level of voluntary MI payment is equivalent to the average level of compulsory MI payment in the region, the voluntary MI card bearer shall be entitled to the MI regime as stipulated in Chapter II of this Regulation.

The Ministry of Health and the Ministry of Finance shall jointly prescribe levels of voluntary MI payment and benefit; the Minister of Health shall provide detailed guidance on the levels of voluntary MI payment and benefit applicable to each locality after consulting the People's Committee of the province or city directly under the Central Government.

Article 24.- Revenues from the voluntary MI shall be subject to separate cost-accounting and used to cover following expenses:

1. Payment of medical examination and treatment costs for voluntary MI card bearers as prescribed.

2. Payment to the agents that collect voluntary MI premiums and distribute voluntary MI cards.

3. Payment for regular management of the MI agency.

The Vietnam Medical Insurance shall have to uniformly manage the voluntary MI fund. The Ministry of Health and the Ministry of Finance shall jointly provide detailed regulations and guidance on the use of the voluntary MI fund.

Chapter VII

ORGANIZATION AND MANAGEMENT OF MEDICAL INSURANCE

Article 25.- The Vietnam Medical Insurance is set up on the basis of unifying the system of MI agencies from the central to the grassroots levels and the branch MI in order to manage and materialize the MI policies according to this Regulation.

Article 26.- The Government assigns the Ministry of Health to exercise the function of State management over the MI. The State management work embraces the following contents:

1. To work out MI policies and legislation and submit them to the higher- level authorities for promulgation or promulgate them according to their competence.

2. To coordinate with the Ministry of Finance and the presidents of the People's Committees of the provinces and cities directly under the Central Government in guiding the implementation of the voluntary MI.

3. To guide examination and inspection of the implementation of the provisions of law on MI.

Article 27.- Vietnam Medical Insurance shall be organized and managed in a concentrated and uniform system from the central to the grassroots levels.

1. At the central level: Vietnam Medical Insurance is attached to the Ministry of Health.

2. At the provincial level: the Medical Insurance of provinces and cities directly under the Central Government and the branch Medical Insurance are attached to Vietnam Medical Insurance;

3. At the district/town/ provincial capital level (collectively referred to as district), MI branches shall be organized directly under the Medical Insurance of the provinces or cities directly under the Central Government.

Vietnam Medical Insurance shall have the tasks and powers: to organize the implementation of the MI Regulation; to manage the collection and spending of the MI fund throughout the country; to propose plans on the preservation and increase of the MI fund and organize the implementation of such plans after they are ratified; to print, issue and manage MI cards; to manage organizations, personnel, State officials and employees and material-technical bases of the whole system of MI agencies in accordance with the State's stipulations.

The regulation on organization and operation of Vietnam Medical Insurance shall be issued by the Minister of Health after consulting the Minister-Head of the Government Commission on Organization and Personnel.

Article 28.- The management council of Vietnam Medical Insurance shall act as the body managing and supervising the operation of Vietnam Medical Insurance.

The management council of Vietnam Medical Insurance shall have the tasks and powers: to direct, supervise and inspect the management, collection and spending of the MI fund; to ratify the plan on regulating the MI funds in the entire system; to decide measures to preserve and increase the MI funds; to approve the annual budget estimates and final account settlements of Vietnam Medical Insurance; to ratify the plan on organization, proposals on the split, merger or dissolution of the member units and propose the appointment or dismissal of the General Director of Vietnam Medical Insurance.

The management council of Vietnam Medical Insurance is composed of its chairman, vice chairmen and members.

The chairman of the management council shall be a leading official of the Ministry of Health to be appointed by the Prime Minister at the proposal of the Minister of Health and the Minister-Head of the Government Commission on Organization and Personnel. Members shall be authorized representatives of the Ministry of Health, the Ministry of Finance, the Ministry of Labor, War Invalids and Social Affairs, the Vietnam Confederation of Labor and Vietnam Medical Insurance.

The Minister of Health shall appoint the vice-chairmen of the management council of the Vietnam Medical insurance and its members after consulting the above-said ministries and branches.

Article 29.- Vietnam Medical Insurance shall be managed and run by its General Director according to the bossism regime. The General Director are assisted by Deputy General Directors.

The Minister of Health shall appoint and/or dismiss the General Director of Vietnam Medical Insurance at the proposal of the management council of Vietnam Medical Insurance and after consulting the Minister-Head of the Government Commission on Organization and Personnel.

The Deputy General Directors of Vietnam Medical Insurance shall be appointed and/or dismissed by the Minister of Health at the proposal of the General Director of Vietnam Medical Insurance.

Directors of the Medical Insurance agencies of the provinces and cities directly under the Central Government and directors of the branch Medical Insurance agencies shall be appointed and/or dismissed by the General Director of Vietnam Medical Insurance after consulting the People's Committees of the provinces and cities directly under the Central Government and the branch leaders.

Chapter VIII

COMMENDATION, SETTLEMENT OF COMPLAINTS AND HANDLING OF VIOLATIONS

Article 30.- Agencies, units and individuals with achievements in the MI cause shall be commended or rewarded in accordance with the general provisions.

Article 31.- Any MI complaint or litigation shall, depending on the matter's characteristics, be settled by the MI agencies of different levels, the competent State management agencies or courts in accordance with the provisions of law.

Article 32.- Agencies, units or individuals that violate the provisions of this Regulation shall, depending on the seriousness of their violations, be handled according to the provisions on sanctions against administrative violations in the field of MI; if damage is caused, compensation therefor must be paid in accordance with the provisions of law.