Summary of new regulations on health insurance effective from December 3, 2023 as stipulated in Decree 75/2023/ND-CP. Readers are invited to refer to the article below.
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| New regulations on health insurance take effect from December 3, 2023. |
New regulations on rights and responsibilities of medical facilities in implementing health insurance medical contracts
The rights and responsibilities of medical examination and treatment facilities (KCB) in implementing the health insurance contract as prescribed in Article 21 of Decree 146/2018/ND-CP are adjusted as follows:
(1) Rights of medical facilities:
- Exercise the rights prescribed in Article 42 of the Law on Health Insurance 2008 and the provisions of the law on medical examination and treatment;
- Provided with timely information when the health insurance appraisal information system detects an increase in health insurance medical examination and treatment costs higher than the average cost of medical examination and treatment facilities of the same class, same level, same specialty to promptly review, verify, and implement appropriate adjustment solutions.
(2) Responsibilities of medical facilities:
- Perform the responsibilities prescribed in Article 43 of the Law on Health Insurance 2008 and the responsibilities prescribed by law on medical examination and treatment;
- Comply with the provisions of the law on medical examination and treatment, professional instructions of the Ministry of Health and relevant legal provisions on procurement and bidding to ensure the supply of drugs, chemicals, medical supplies and medical technical services with quality, efficiency and economy;
- Send electronic data to serve the management of health insurance coverage immediately after the end of the medical examination or the end of the outpatient treatment or the end of the inpatient treatment of the patient according to the regulations of the Minister of Health;
- Send electronic data on health insurance medical examination and treatment costs for payment requests no later than 07 working days from the date of completion of medical examination and treatment for the patient according to regulations of the Minister of Health.
- Establish an information technology infrastructure system, upgrade and complete the hospital management software system to comply with legal regulations on input data standards, output data standards, electronic data extraction and transfer, digital transformation and electronic transactions in the medical field;
- Review and promptly issue procedures and professional instructions in health insurance treatment, measures to prevent abuse and profiteering of health insurance funds according to authority; organize inspection and review of the implementation of payment of health insurance treatment costs in accordance with the provisions of law; proactively detect, review, verify and inspect increased health insurance treatment costs at facilities according to recommendations and warnings of social insurance agencies and make appropriate adjustments.
Amending the principle of payment of health insurance medical examination and treatment costs according to service prices
The new regulations on the principles of payment of health insurance medical examination and treatment costs according to service prices in Clause 3, Article 24 of Decree 146/2018/ND-CP are amended as follows:
- Costs of medical examination services, costs of hospital bed days and costs of technical services and tests used for patients within the scope of benefits and levels of benefits of health insurance participants are paid according to the actual quantity used for patients and the price according to current regulations;
- The cost of drugs, chemicals, and medical supplies not included in the price of health insurance services or used in technical services for which the price of health insurance services has not been issued and has been used for patients within the scope of benefits and the level of benefits of health insurance participants shall be paid according to the actual quantity used and the purchase price according to the provisions of the law on bidding;
- Blood and blood product costs are paid according to the instructions of the Minister of Health.
New regulations on financial planning and settlement of health insurance fund
Regulations on financial planning and settlement of health insurance fund in Article 36 of Decree 146/2018/ND-CP are amended as follows:
(i) Every year, Vietnam Social Security shall prepare a financial plan for the collection and expenditure of the health insurance fund; the management costs of the health insurance fund and investment from the temporarily idle funds of the health insurance fund. The Ministry of Finance shall preside over and coordinate with the Ministry of Health to review, synthesize and submit to the Prime Minister for assignment of the financial plan.
(ii) Prepare and assign the budget for health insurance examination and treatment expenses and notify the estimated amount of health insurance examination and treatment expenses:
- Vietnam Social Security shall prepare the following year's health insurance expenditure estimate (including the budget of the Ministry of National Defense Social Security and the People's Public Security Social Security) and send it to the Ministry of Finance before August 30 every year. The Ministry of Finance shall preside over and coordinate with the Ministry of Health to synthesize and submit to the Prime Minister the health insurance expenditure estimate from the revenue estimate and reserve fund for Vietnam Social Security;
- Based on the budget assigned by the Prime Minister, Vietnam Social Security assigns the budget for health insurance expenditure to the Ministry of National Defense Social Security, the People's Public Security Social Security, and the Social Security of provinces and centrally run cities within 90% of the national health insurance revenue budget;
- Based on the request of the medical examination and treatment facility, the Social Insurance of the provinces and centrally run cities shall notify the estimated amount of health insurance medical examination and treatment expenditure to the medical examination and treatment facility (not applicable as a basis for advance payment, payment, and settlement of health insurance medical examination and treatment costs of the medical examination and treatment facility in case of exceeding the estimated amount of expenditure). In case the medical examination and treatment facility has an estimated amount of expenditure in the year that increases or decreases compared to the announced amount, the facility shall send a written document to the Social Insurance of the province or centrally run city before October 15 of each year for synthesis and adjustment within the budget assigned by the Social Insurance of the province or centrally run city;
- In case the total estimated health insurance expenditure of health care facilities, the estimated actual health insurance expenditure of the Ministry of National Defense Social Insurance and the People's Public Security Social Insurance in the year increases or decreases compared to the estimate assigned by the Vietnam Social Insurance, the Social Insurance of provinces and centrally run cities, the Ministry of National Defense Social Insurance and the People's Public Security Social Insurance shall synthesize and send to the Vietnam Social Insurance before October 30 every year for consideration and adjustment between the provinces and centrally run cities and the Ministry of National Defense Social Insurance and the People's Public Security Social Insurance.
Vietnam Social Security synthesizes and considers adjusting the estimated health insurance expenditure between the Social Security of provinces and centrally run cities, the Social Security of the Ministry of National Defense, and the Social Security of the People's Public Security within the estimated budget assigned by the Prime Minister before November 15 every year to serve as a basis for adjusting the estimated health insurance expenditure of health care facilities.
(iii) Supplement the health insurance medical examination and treatment expenses for medical examination and treatment facilities in case the actual health insurance medical examination and treatment expenses in the year of the medical examination and treatment facility after being appraised by the Social Insurance agency exceed the expected expenditure (including the number notified at the beginning of the year and the number adjusted during the year) and exceed the estimated health insurance medical examination and treatment expenses assigned by Vietnam Social Insurance to be implemented as follows:
- The Social Insurance of provinces and centrally run cities shall preside over and coordinate with the Department of Health and medical examination and treatment facilities to review and determine the cost of health insurance medical examination and treatment exceeding the expected amount of payment and supplement the budget for the medical examination and treatment facilities.
- In case the budget allocated by Vietnam Social Security is not enough to supplement the budget for medical examination and treatment facilities, the Social Security of provinces and centrally-run cities, the Social Security of the Ministry of National Defense, and the Social Security of the People's Public Security will compile and send it to Vietnam Social Security for consideration and supplement the budget for health insurance medical examination and treatment.
(iv) In case the total actual health insurance payment settlement in the year exceeds the estimate assigned by the Prime Minister, Vietnam Social Security shall supplement the health insurance payment fund to pay for health insurance facilities from the reserve fund and compile a report to send to the Social Security Management Council, the Ministry of Finance, the Ministry of Health and the Prime Minister.
In case the health insurance reserve fund is not enough to supplement the medical examination and treatment costs for provinces and centrally run cities, the Ministry of National Defense Social Insurance, the People's Public Security Social Insurance, and the implementing agencies shall comply with the provisions of Clause 3, Article 35 of Decree 146/2018/ND-CP.
(v) Advance payment, payment and settlement of health insurance medical examination and treatment costs for medical examination and treatment facilities are made quarterly in accordance with the provisions in Clauses 1 and 2, Article 32 of the Law on Health Insurance 2008.
(vi) Every year, before October 1, Vietnam Social Security is responsible for synthesizing and preparing a report on the settlement of the health insurance fund of the previous year according to the provisions of Article 32 of the Law on Health Insurance 2008.
Adjusting regulations on responsibilities for guiding the implementation of Decree 146/2018/ND-CP
Clause 10, Article 1 of Decree 75/2023/ND-CP amends the provisions of a number of clauses of Article 42 of Decree 146/2018/ND-CP regulating the responsibility for guiding the implementation of Decree 146/2018/ND-CP.
Accordingly, the regulations on responsibility for guiding the implementation of Decree 146/2018/ND-CP after adjustment are as follows:
(a) The Ministry of Health is responsible for:
- Guidance on the implementation of the articles and provisions assigned in Decree 146/2018/ND-CP;
- Preside over and coordinate with relevant ministries and agencies to inspect the implementation of policies and laws on health insurance;
- Guidance on assessing conditions for signing initial medical examination and treatment contracts for health insurance facilities;
- Issue a set of codes for common use nationwide, including: Medical technical services, modern medicine, traditional medicine, medical supplies, equipment, blood and blood products, traditional medicine diseases, disease diagnosis codes according to the international classification (ICD), medical facility codes and codes that meet management requirements;
- Direct medical examination and treatment facilities to enhance the application of information technology in medical examination and treatment; promptly, accurately and fully update information on health insurance medical examination and treatment and transfer data to the health insurance medical examination and treatment data receiving system of the Ministry of Health and the appraisal information system of Vietnam Social Security to serve health insurance management and appraisal and payment of health insurance medical examination and treatment costs;
- Specific regulations on the application of information technology in health insurance examination and treatment;
- Regulations and instructions for implementing data connection on test results, diagnostic imaging, functional examination, and medical examination information of patients participating in health insurance (revised)
- Preside over and coordinate with the Ministry of Finance and Vietnam Social Security to develop a report for the Government to submit to the National Assembly on the implementation of health insurance policies and regimes, including the management and use of the health insurance fund on an ad hoc, periodic or annual basis.
- Direct medical examination and treatment facilities and centralized purchasing units to strictly implement regulations related to procurement and bidding to ensure timely supply of drugs, chemicals, medical supplies within the scope of benefits of health insurance participants, improve thrift practices, and combat waste. Direct medical examination and treatment facilities to comply with legal regulations on medical examination and treatment, professional instructions of the Ministry of Health; legal regulations related to the provision of medical technical services to ensure quality, efficiency and savings. Review and update according to practical requirements the lists, conditions, scope, and payment rates for drugs, supplies, technical services, and goods within the scope of payment of the health insurance fund to ensure effective management and use of the fund (new addition)
(b) The Ministry of Finance is responsible for:
- Balance and arrange the central budget to support localities that have not been able to balance their budgets to ensure resources for implementing health insurance policies according to the provisions of the law on the state budget;
- Report to the Government on the management and use of the health insurance fund periodically every year or suddenly at the request of the Government;
- Report on the management and use of the health insurance fund annually and send it to the Ministry of Health for synthesis according to regulations;
(c) The Ministry of National Defense and the Ministry of Public Security are responsible for guiding the implementation of health insurance for subjects under the management of the Ministry of National Defense and the Ministry of Public Security according to the provisions of Clause 1, Article 1; Clauses 13 and 15, Article 3; Clause 3, Article 4 and Article 6 of Decree 146/2018/ND-CP.
(d) The Ministry of Labor, War Invalids and Social Affairs is responsible for:
- Research and develop criteria to identify households engaged in agriculture, forestry, fishery and salt production with an average living standard suitable to the socio-economic situation of each period, and submit to the Prime Minister for promulgation;
- Instructions for making a list of subjects specified in Clauses 3, 5, Point a, Clauses 9, 11, 12, 16 and 17, Article 3, Clauses 1, 2 and 4, Article 4 of Decree 146/2018/ND-CP.
(d) Vietnam Social Security:
- Directing social insurance agencies at all levels to sign contracts with qualified medical facilities according to the provisions of this Decree;
- Directing Social Insurance agencies of provinces and cities to coordinate with the Department of Health, Department of Finance and health insurance medical facilities in the area, neighboring areas and related agencies to resolve within their authority or recommend competent authorities to promptly consider and handle arising problems;
- Directing Social Insurance at all levels to provide forms and instructions to People's Committees at commune level in making lists and managing lists of health insurance participants by household;
- Complete the information technology system to meet the requirements of receiving, appraising and promptly responding to health care facilities about health insurance data; ensure accuracy, safety, confidentiality of information and rights of related parties; proactively review, detect and promptly send warning information to health care facilities about health insurance costs that are higher than the average cost of health care facilities of the same class, same route, same specialty (revised);
- Synthesize, report periodically, annually or report suddenly at the request of state management agencies on the implementation of health insurance regimes and policies; the collection, expenditure, management and use of health insurance funds and send them to the Ministry of Health and the Ministry of Finance for synthesis according to the provisions of this Decree;
- Regulations on the authority to sign health insurance contracts between social insurance agencies and health care facilities ensure compliance with the functions, tasks, powers and organizational structure of Vietnam Social Security;
- By January 1, 2020 at the latest, the Social Insurance agency must issue electronic health insurance cards to health insurance participants.
(e) The People's Committees of provinces and centrally run cities are responsible for submitting to the People's Councils of the same level to ensure funding for health insurance contributions for subjects whose health insurance contributions are paid or supported by the state budget according to current regulations.
Above are important new regulations on health insurance that will take effect from December 3, 2023. See more detailed regulations in Decree 75/2023/ND-CP.
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