Circular 04/2021/TT-BYT on capitation payment of health insurance-covered medical care costs

CIRCULAR

Providing guidance on capitation payment of health insurance-covered medical care costs

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Pursuant to the Law on Health Insurance No. 25/2008/QH12 dated November 14, 2008, amended and supplemented by the Law No. 46/2014/QH13 dated June 13, 2014;

Pursuant to the Government’s Decree No. 146/2018/ND-CP dated October 17, 2018, detailing, and guiding measures to implement, a number of articles of the Law on Health Insurance;

Pursuant to the Government’s Decree No. 75/2017/ND-CP dated June 20, 2017, defining the functions, tasks, powers and organizational structure of the Ministry of Health;

At the proposal of the Director of the Department of Planning and Finance,

The Minister of Health hereby promulgates the Circular providing guidance on capitation payment of health insurance-covered medical care costs.

Chapter I

GENERAL PROVISIONS

              Article 1. Scope of regulation and application

1. This Circular provides guidance on:

a) The determination of capitation funds;

b) Allocation, advance payment and settlement of capitation funds;

c) Capitation performance monitoring index.

2. This Circular does not apply to health establishments (hereinafter referred to as establishments) that have just entered into health insurance-covered medical care contracts in the preceding year.

              Article 2. Interpretation of terms

1. Capitation fund means a pre-determined amount, assigned to a health insurance-covered medical care provider to provide outpatient medical care services for a health insurance card holder within the capitation in a certain period of time.

2. Age group means the insured prescribed in this Circular that is classified into 6 groups by year of birth as follows:

a) Group 1: Children aged between 0 and 6 years;

b) Group 2: Children aged between 7 and 18 years;

c) Group 3: Persons aged between 19 and 24 years;

d) Group 4: Persons aged between 25 and 49 years;

dd) Group 5: Persons aged between 50 and 59 years;

e) Group 6: Persons aged 60 years or older.

3. Conversion card means a health insurance card of registration for initial medical care, which is converted for the full duration of the fund allocation and at the expense of each age group within the capitation specified in Clause 2 of this Article.

4. Equivalent card means a health insurance card with the same demand for resources for a medical visit within the capitation, the number of equivalent cards of an establishment is the total number of outpatient medical visits within the capitation of health insurance card holders who come for initial and multi-line medical care at establishments whose charges have been adjusted according to the age group and the their conversion card number.

5. Basic charge means an amount paid for an equivalent card, that is applied nationwide or in a province or centrally-run city (hereinafter referred to as the province).

6. Fund allocation coefficient means a coefficient used to adjust the provincial capitation fund (hereinafter referred to as k_province) or establishment's capitation fund (hereinafter referred to as k_{establishment)}.

7. Surplus balance means the larger difference between the settled capitation fund and the total amount of health insurance-covered outpatient medical care costs within the establishment's capitation that has already been implemented at the end of the fund allocation period.

8. Cost increased or reduced due to policy changes means an amount determined for each establishment upon settling health insurance-covered outpatient medical care costs of the year of fund allocation based on changes in legal documents that affect to health insurance-covered medical care costs.

              Article 3. Capitation scope

1. The scope of capitation for establishments at the district level or below is the entire outpatient medical care costs within the scope of benefit of the insured, except for the case specified in Clause 3 of this Article.

2. The scope of capitation applicable to provincial-level and central-level establishments: Applies to all establishments providing initial medical care services as registered in health insurance cards and all outpatient medical care costs within the capitation of patients who register for initial medical care that arise at the establishments, except for the case specified in Clause 3 of this Article.

3. Medical care costs of the following subjects, diseases and groups of diseases shall not be included in the capitation scope:

a) Expenses of subjects with military (QN), ciphers (CY), police (CA) card codes;

b) Expenses for transportation of health insurance card holders;

c) The entire health insurance-covered medical care costs with the use of cyclic artificial kidney technology or peritoneal dialysis or peritoneal dialysis services;

d) The entire costs of the health insurance-covered medical visits with the use of anti-cancer drugs or cancer treatment intervention services for patients diagnosed with cancer, including codes from C00 to C97 and codes from DOO to D09 belong to the X^th International Classification of Diseases (hereinafter referred to as ICD-10);

dd) The entire costs of the health insurance-covered medical visits with the use of hemophilia treatment drugs or blood or blood products for patients diagnosed with hemophilia, including the following codes: D66, D67, D68 of the ICD-10 set code;

e) The entire costs of the health insurance-covered medical visits with the use of immunosuppressant (anti-rejection) drugs for organ transplant patients;

e) The entire costs of the health insurance-covered medical visits with the use of drugs to treat hepatitis C of the patient with hepatitis C;

h) The entire costs of the health insurance-covered medical visits with the use of anti-HIV drugs or HIV load testing services of health insurance card holders who are diagnosed with HIV disease.

Chapter II

DETERMINATION OF CAPITATION FUNDS

              Article 4. National capitation fund

1. National capitation fund (hereinafter referred to as QUY_DStq) of the fund allocation year shall be determined according to the following formula: