THE MINISTRY OF HEALTH
______ No. 04/2021/TT-BYT | THE SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom - Happiness _______________________ Hanoi, April 29, 2021 |
CIRCULAR
Providing guidance on capitation payment of health insurance-covered medical care costs
__________
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 kprovince) or establishment's capitation fund (hereinafter referred to as kestablishment).
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 Xth 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:
QUY_DStq | = | Total national capitation fund of the preceding year that is settled | + | Amount of difference due to increase or decrease of the number of conversion cards between the fund allocation year and the preceding year | + | Costs increased or reduced due to policy changes |
In which:
a) Total national capitation fund of the preceding year that is settled means the total amount of money within the scope of the capitation fund in the preceding year of each establishment that is settled according to this Circular;
b) Amount of difference due to increase or decrease of the number of conversion cards between the fund allocation year and the preceding year shall be determined according to the following formula:
Amount of difference due to increase or decrease of the number of conversion cards between the fund allocation year and the preceding year | = | T_TTDS country in the preceding year | x | Difference in the number of conversion cards in the fund allocation year increased or decreased compared to the preceding year |
The number of national conversion cards in the preceding year |
In which:
- T_TTDS country = Total settlement amount for capitation (hereinafter referred to as T_TTDS) of all province in the country;
- T_TTDS province = Total T_TTDS of all establishments providing medical care services according to capitation of the province;
- T_TTDS establishment = (The establishment's annual capitation fund settled under Article 11 of this Circular) + (The amount increased or decreased due to policy changes specified in Clause 8, Article 2 of this Circular).
2. The number of national conversion cards, national card conversion coefficient
a) The number of national conversion cards is equal to the total number of conversion cards of provinces;
b) The number of conversion cards in the fund allocation year of the province (hereinafter referred to as The QDprovince) = Total [(number of health insurance cards off registration for initial medical care according to the age group of the province in the year of fund allocation) from January 01 to December 31 of the fund allocation year) x (National card conversion coefficient according to that age group of the year of fund allocation)].
6 The QDprovince = ∑ i=1 | (The DKBD for the year of allocation of fundprovince i x HSQDTtqi) |
In which:
- i refers to the ith age group, in which has the value from 1 to 6 corresponding to 6 age groups as prescribed in Clause 2, Article 2 of this Circular;
- The DKBD for the year of allocation of fundprovince is the health insurance cards of registration for initial medical care of the fifth age group, the ith age group in the year of allocation of the provincial capitation fund, which have been calculated for a full year;
- HSQDTtqi is the national card conversion coefficient according to the ith age group of the year of fund allocation calculated by the following formula:
HSQDTtqi = | Average cost on one national health insurance card of age group i in the preceding year |
Average cost on one national health insurance card in the preceding year |
In which:
Average cost on one national health insurance card of age group i in the preceding year | = | T_BHTT paid for age group i of the whole country in the preceding year |
Total health insurance cards for age group i of the whole country in the preceding year, which have been calculated for a full year |
Average cost on one national health insurance card in the preceding year | = | T_BHTT paid for all age groups of the whole country in the preceding year |
Total health insurance cards of the whole country in the preceding year, which have been calculated for a full year |
In which:
- T_BHTT country = Total settle and paid health insurance-covered medical care costs (hereinafter referred to as T_BHTT) of provinces in the country;
- T_BHTT province = Total T_BHTT of all establishments providing medical care services according to capitation of the province;
- T_BHTT establishment = Amount determined according to the examination record of payment for health insurance-covered medical care costs within the scope of the health insurance fund of the provincial social security agency.
Article 5. National basis charges
1. National basis charges of the fund allocation year (hereinafter referred to as SPCBtq) shall be calculated according to the following formula:
In which:
a) QUY_DStq shall comply with Clause 1, Article 4 of this Circular;
b) The TDtq means the number of national equivalent cards in the fund allocation year that is equal to the number of equivalent cards of all provinces in the fund allocation year.
2. The number of equivalent cards in the fund allocation year of the province = (The number of intra-provincial equivalent cards in the fund allocation year of the province) + (The number of multi-line equivalent cards to the outer provinces in the year of fund allocation of the province).
a) The number of intra-provincial equivalent cards in the fund allocation year of the province shall be equal to the total number of intra-provincial equivalent cards according to 6 age groups specified in Clause 2, Article 2 of this Circular in the fund allocation year of that province. The number of intra-provincial equivalent cards in the fund allocation year of age group i of the province (hereinafter referred to as The TD intra-province of group i in the fund allocation year) shall be determined according to the following formula:
The TD intraprovince of group i in the fund allocation year | = | The number of intra-provincial visits of group iprovince ntlk | x | The QD of group iprovince in the fund allocation year | x | Visit conversion coefficient of group icountry in the fund allocation |
The QD of group iprovince ntlk |
In which:
- The number of intra-provincial visits of group iprovince ntlk means the number of medical visits at establishments located in the province in the preceding year of patients of age group i whose health insurance cards are registered at provincial level (excluding health insurance cards issued by other provinces);
- The QD of group iprovince ntlk means the number of conversion cards of age group in the preceding year of the province;
- The QD of group iprovince in the fund allocation year means the number of conversion cards of age group in the fund allocation year of the province;
- Visit conversion coefficient of group icountry in the fund allocation means the visit conversion coefficient of age group i of the whole country in the fund allocation year.
b) The number of multi-line equivalent cards to the outer provinces of the province shall be equal to the total number of multi-line equivalent cards of 6 age groups specified in Clause 2, Article 2 of this Circular.
The number of multi-line equivalent cards of age group i of the province in the fund allocation year | = | The number of health insurance-covered outpatient medical visits of age group i of the province in the preceding year | x | National visit conversion coefficient of group i in the fund allocation |
c) National visit conversion coefficient according to the age group i (hereinafter referred to as HSQĐLtqi) of the year of fund allocation shall be calculated by the following formula:
HSQDLtqi = | Average cost on a visit of age group i of the whole country in the preceding year |
Average cost on a medical visit of the whole country in the preceding year |
In which:
Average cost on a visit of age group i of the whole country in the preceding year | = | T_BHTT paid for the age group i in the preceding year of the whole country |
Total medical visits of age group i of the whole country in the preceding year |
Average cost on a medical visit of the whole country in the preceding year | = | T_BHTT paid for 6 age groups of the whole country in the preceding year |
Total medical visits of all age groups of the whole country in the preceding year |
Article 6. Provincial capitation funds
1. Provincial capitation fund of the fund allocation year (hereinafter referred to as QUY_DSprovince) shall be calculated according to the following formula:
QUY_DSprovince = SPCBtq x | The number of equivalent cards in the fund allocation year of the province | x k1province x k2dctqtq x k3province |
In which:
a) SPCBtq shall comply with Clause 1, Article 5 of this Circular;
b) The number of equivalent cards in the fund allocation year of the province shall comply with Clause 2, Article 5 of this Circular;
c) k1province is the cost adjustment coefficient of the province according to the average cost of the whole country and it is required to ensure that the province's capitation fund temporarily determined according to the coefficient k = k1 (excluding the coefficient k2) must not exceed 110% (one hundred and ten percent) or less than 90% (ninety percent) when there are the same number of conversion cards of the province. k1province shall be calculated according to the following formula:
k1province = | TLHS x CPBQ The TDprovince ntlk + (1-TLHS) x CPBQ The TDtq ntlk |
CPBQ The TDtq ntlk |
In which:
- TLHS means the rate of application of the cost coefficient performed according to the roadmap specified in Clause 2, Article 15 of this Circular.
- CPBQ The TDtq ntlk means an average cost on an equivalent card in the preceding year of the province that is determined according to the following formula:
CPBQ The TDtq ntlk = | T_TTDS province in the preceding year |
The number of equivalent cards in the preceding year of the province |
- CPBQ The TDtq ntlk means an average cost on an equivalent card of the whole country in the preceding year of the province that is determined according to the following formula:
CPBQ The TDtq ntlk = | T_TTDS country in the preceding year |
The number of equivalent cards in the preceding year of the country |
d) k2dctqtq means the adjustment coefficient to ensure that the total capitation funds allocated to provinces in the country is equal to the total national capitation fund that is calculated according to the following formula:
k2dctqtq = | QUY_DStq |
∑nj=1(QUY_DSprovince tt j) |
In which:
- n is the number of provinces allocating medical care funds according to capitation;
- QUY_DStq shall comply with Clause 1, Article 4 of this Circular;
- QUY_DStq is the province’s capitation fund temporarily determined according to the coefficient k1 that has been adjusted, provided that it must not exceed 110% (one hundred and ten percent) or must not less than 90% (ninety percent) compared to T_TTDS province of the preceding year with the same number of conversion cards (excluding the coefficient k2) of the province.
- j is the ordinal number of the jth province, in which j has a value from 1 to n corresponding to the number of provinces allocating medical care funds according to capitation.
dd) k3province is the different adjustment coefficient of the province, k3province is equal to 1 in the first year of implementation. k3province in the following years shall be decided by the Minister of Health. In case specific regulation is not available, k3province shall be equal to 1.
2. Costs increased or reduced due to policy changes are not included in the provincial capitation fund. The determination of costs increased or reduced due to policy changes shall comply with the Ministry of Health's notices. In case the Ministry of Health's notice is not available, cost increased or reduced due to policy changes is zero (0).
3. Provincial capitation fund shall be allocated to all establishments in the year of fund allocation.
Article 7. Provincial basis charges
1. Provincial basis charges of the fund allocation year (hereinafter referred to as SPCBprovince) shall be calculated according to the following formula:
SPCBprovince = | QUY_DSprovince |
The TDprovince |
In which:
a) QUY_DSprovince shall comply with Clause 1, Article 6 of this Circular;
b) The TDprovince is the number of equivalent cards of the province in the fund allocation year.
2. The number of equivalent cards of the province in the fund allocation year must be equal to the total number of equivalent cards of establishments implementing capitation in the province in the fund allocation year.
3. The number of equivalent cards of the establishment implementing capitation in the fund allocation year = (The number of equivalent cards for health insurance-covered initial medical care at the establishment in the fund allocation year) + (The number of multi-line equivalent cards of the establishment in the fund allocation year).
a) The number of equivalent cards for health insurance-covered initial medical care at the establishment in the fund allocation year is equal to the total number of equivalent cards for health insurance-covered initial medical care according to 6 age groups as prescribed in Clause 2 Article 2 of this Circular in the fund allocation year of the establishment.
The number of equivalent cards for initial medical care of age group i in the fund allocation year of the establishment shall be determined according to the following formula:
Equivalent cards of initial medical care of the establishment of group i in the fund allocation year | = | The number of initial medical visits of group iestablishment ntlk | x | The QD of group iestablishment in the fund allocation year | x | Visit conversion coefficient of group iprovince in the fund allocation |
The QD of group iestablishment ntlk |
In which:
- The number of number of initial medical visits of group iestablishment ntlk means the number of medical visits at the establishments registered as the initial medical care service providers in the preceding year of health insurance card holders of age group i;
- The QD of group iestablishment ntlk means the number of conversion cards of age group i of the establishment in the preceding year;
- The QD of group iestablishment in the fund allocation year means the number of conversion cards of age group i of the establishment in the fund allocation year;
- Visit conversion coefficient of group iprovince in the fund allocation means the visit conversion coefficient of age group i of the whole province in the fund allocation year.
- Provincial visit conversion coefficient according to the age group i of the year of fund allocation shall be calculated by the following formula:
Visit conversion coefficient of group iprovince in the fund allocation | = | Average cost on a visit of age group i of the province in the preceding year |
Average cost on a visit of 6 age groups of the province in the preceding year |
In which:
Average cost on a visit of age group i of the province in the preceding year | = | T_BHTT paid for age group i of the province in the preceding year |
Total health insurance-covered medical visits of age group i of the province in the preceding year |
Average cost on a visit of all age groups of the province in the preceding year | = | T_BHTT province in the preceding year |
Total medical visits of all age groups of the province in the preceding year |
b) The number of multi-line equivalent cards of the establishment in the fund allocation year shall be equal to the total number of multi-line equivalent cards of 6 age groups specified in Clause 2, Article 2 of this Circular.
The number of multi-line equivalent cards of age group i of the establishment in the fund allocation year = (The number of multi-line medical visits according to age group i of the establishment in the preceding year) x (provincial visit conversion coefficient by age group i in the fund allocation year specified at Point a of this Clause).
Article 8. Establishment's capitation funds
1. Establishment's capitation fund of the fund allocation year shall be determined according to the following formula:
Establishment's capitation fund | = SPCBprovince x | The number of equivalent cards of the establishment in the fund allocation year | x k1establishment x k2dctqprovince x k3establishment |
In which:
a) SPCBprovince shall comply with Clause 1, Article 7 of this Circular;
b) The number of equivalent cards of the establishment in the fund allocation year shall comply with Clause 3, Article 7 of this Circular;
c) k1establishment is the cost adjustment coefficient of the establishment according to the average cost of the province and it is required to ensure that the capitation fund temporarily determined according to the coefficient k = k1 (excluding the coefficient k2) must not exceed 110% or less than 90% when there are the same number of conversion cards of the establishment. k1establishment shall be calculated according to the following formula:
k1establishment = | TLHS x CPBQ The TDestablishment ntlk + (1-TLHS) x CPBQ The TDprovince ntlk |
CPBQ The TDprovince ntlk |
In which:
- TLHS means the rate of application of the cost coefficient performed according to the roadmap specified in Clause 2, Article 15 of this Circular.
- CPBQ The TDestablishment ntlk means an average cost on an equivalent card in the preceding year of the province that is determined according to the following formula:
CPBQ The TDprovince ntlk | T_TTDS establishment |
The number of equivalent cards of the establishment in the preceding year |
d) k2dctqprovince means the adjustment coefficient to ensure that the total capitation funds allocated to establishments in the province is equal to the total provincial capitation fund that is calculated according to the following formula:
k2dctqprovince = | QUY_DSprovince |
∑nj=1(QUY_DSestablishment tt j) |
+ n is the number of establishments settling and paying health insurance-covered medical care costs according to capitation in the province;
+ QUY_DSprovince shall comply with Article 6 of this Circular;
+ QUY_DSestablishment tt is the establishment's capitation fund temporarily determined according to the coefficient k equal to k1 that has been adjusted to ensure that it does not exceed 110% or is not less than 9% compared with costs of the preceding year with the same number of conversion cards (excluding the coefficient k2) of that establishment;
+ j is the ordinal number of the jth establishment, in which j has a value from 1 to n corresponding to the number of establishments paying and settling health insurance-covered medical care costs according to capitation in the province.
dd) k3establishment is the different adjustment coefficient of the establishment, k3establishment is equal to 1 in the first year of implementation. In the following years, k3establishment shall be decided by the provincial-level Department of Health and provincial social security agencies. In case specific regulation is not available, k3establishment shall be equal to 1.
2. Costs increased or reduced due to policy changes are not included in the establishment's capitation fund. The determination of costs increased or reduced due to policy changes shall comply with the Ministry of Health's notices. In case the Ministry of Health's notice is not available, cost increased or reduced due to policy changes is zero (0).
Chapter III
ALLOCATION, ADVANCE PAYMENT AND SETTLEMENT OF CAPITATION FUNDS
Article 9. Allocation of capitation funds for provinces
1. Before January 15 of the year of fund allocation, the Vietnam Social Security shall be responsible for notifying provincial Social Security of:
a) Provincial capitation funds temporarily allocated in the year of fund allocation after reaching an agreement with the Ministry of Health. The determination of temporarily allocated capitation funds shall comply with Clause 2 of this Article;
b) Provincial capitation funds of the year preceding the year of fund allocation.
2. Temporarily allocated capitation fund of the province shall be determined according to Article 6 of this Circular, in which, data shall be temporarily determined as follows:
a) The settled national capitation fund of the preceding year shall be equal to the total national capitation fund temporarily allocated in the preceding year;
b) National basis charges temporarily allocated at the beginning of the year = (95% (ninety five percent) temporarily determined national capitation fund specified at Point a of this Clause) : (The number of national equivalent cards specified at Point b, Clause 1, Article 5 of this Circular);
c) The number of conversion cards of the preceding year of each province shall be temporarily determined based on the number of cards issued by the social security agencies in the preceding year of each province, which have been converted according to the national card conversion coefficient;
d) The number of visits, T_BHTT province of the preceding year shall be temporarily determined by the medical visits and costs of health insurance-covered outpatient medical care within the capitation scope requested by the establishment on the health insurance examination information system in the preceding year of the province;
dd) T_TTDS province in the preceding year shall be temporarily determined by capitation fund temporarily allocated for the preceding year that has been adjusted in the fourth quarter of the preceding year of the province;
e) The number of conversion cards in the fund allocation year of each province shall be temporarily determined by the number of health insurance cards in the first quarter in the fund allocation year of each province, which have been converted according to the national card conversion coefficient.
Article 10. Allocation of capitation funds for establishments
1. Before January 30 of the fund allocation year, provincial social security shall, based on the notice on the temporarily allocated provincial capitation fund under Clause 1, Article 9 of this Circular, take responsibility for notifying establishments of:
a) Establishment’s capitation fund temporarily allocated in the year of fund allocation after reaching an agreement with the provincial-level Department of Health. The determination of capitation fund temporarily allocated to each establishment in the area shall comply with Clause 3 of this Article;
b) Establishment’s capitation fund of the year preceding the year of fund allocation.
2. Based on the temporarily allocated capitation fund of each establishment, provincial social security shall be responsible for allocating capitation fund to each establishment by quarter with the rate and time limit as follows:
a) Fund of the first quarter shall be allocated before January 30 of the fund allocation year with an amount equal to 22% (twenty two percent) of the temporarily allocated capitation fund;
b) Fund of the second quarter shall be allocated before April 15 of the fund allocation year with an amount equal to 24% (twenty four percent) of the temporarily allocated capitation fund;
c) Fund of the third quarter shall be allocated before July 15 of the fund allocation year with an amount equal to 27% (twenty seven percent) of the temporarily allocated capitation fund;
d) Fund of the fourth quarter shall be allocated before October 15 of the fund allocation year with an amount equal to 27% (twenty seven percent) of the temporarily allocated capitation fund.
3. Capitation fund temporarily allocated at the beginning of the year to the establishment shall be determined according to Article 8 of this Circular, in which, data shall be temporarily determined as follows:
a) Temporarily determined provincial capitation fund shall be equal to total provincial capitation fund notified at the beginning of the year;
b) Provincial basis charges = (95% (ninety nine percent) of provincial capitation fund temporarily allocated at the beginning of the year) : (The number of provincial equivalent cards specified in Clause 2, Article 7 of this Circular);
c) The number of conversion cards of the preceding year of each establishment shall be temporarily determined based on the number of cards issued by the social security agencies in the preceding year of each province, which have been converted according to the provincial card conversion coefficient;
d) The number of visits, T_BHTT establishment of the preceding year shall be temporarily determined by the medical visits and costs of health insurance-covered outpatient medical care within the capitation scope requested by the establishment on the health insurance examination information system in the preceding year of the establishment;
dd) T_TTDS establishment in the preceding year shall be temporarily determined by capitation fund temporarily allocated for the preceding year that has been adjusted in the fourth quarter of the preceding year of the establishment;
e) The number of conversion cards in the fund allocation year of each establishment shall be temporarily determined by the number of health insurance cards of registration for initial medical care in the first quarter in the fund allocation year, which have been converted according to the provincial card conversion coefficient.
Article 11. Settlement of the capitation fund for an establishment
1. The establishment capitation fund shall be settled on a quarterly basis, according to the according to the amount allocated to the establishment as specified in Clause 2, Article 10 of this Circular.
2. The establishment capitation fund of a year to be settled shall be equal to the fund amount determined according to Article 8 of this Circular when the establishment satisfies all following conditions:
a) Rate of admission for inpatient treatment within the capitation is not greater than the one of the preceding year;
b) The frequency of multi-line of patients registering for initial medical care is not greater than the one of the preceding year;
c) The referral rate, for multi-line patients getting outpatient medical care at the provincial and central levels within the capitation of the year of fund allocation is not greater than the one of the preceding year;
3. In case the establishment fails to satisfy the conditions specified in Clause 2 of this Article, the grassroots-level capitation fund of the year to be settled = (the fund determined according to Article 8 of this Circular) - (the amount to be deducted determined according to Articles 12 and 13 of this Circular, corresponding to the rate of increase).
For example:
- If the establishment has an increased rate of admission for inpatient treatment, the deductible amount shall be determined according to Article 12 of this Circular;
- If the establishment has an increased frequency of multi-line of patients registering for initial medical care, the deductible amount shall be determined according to Clause 1, Article 13 of this Circular;
- If the establishment has an increase in both rate of admission for inpatient treatment and frequency of multi-line of patients registering for initial medical care, the deductible amount shall be equal to the sum of the amount specified in Article 12 of this Circular and the amount determined according to Clause 1, Article 13 of this Circular.
4. The difference between the provisional capitation fund of the first, second, and third quarters and the establishment’s expenditure of capitation fund of the year that is settled shall be adjusted by the health insurance fund in the fourth-quarter period of settlement of the capitation fund.
5. In case the establishment terminates the contract for health insurance-covered medical care contract in the year of implementation, the settlement amount of the capitation fund shall be corresponding to the duration of performing regulations on capitation.
6. In case the capitation fund allocated in the year of implementation is larger than the health insurance-covered medical care costs (the surplus balance of the capitation fund):
a) The establishment may retain the maximum surplus balance amount equal to 20% (twenty percent) of its total allocated capitation fund for the whole year. Such surplus balance amount of the capitation fund shall be used to calculate the establishment's capitation fund of the preceding year. After the establishment retains 20% of the surplus balance (if any), the remains shall be transferred to the provincial-level capitation fund and not included in the establishment's capitation fund for the preceding year;
b) The establishment shall account the surplus balance specified at Point a of this Clause into its revenue source. The management and use of such surplus balance shall comply with the law regulations;
c) If the grassroots-level capitation fund includes medical care costs of the affiliated establishments, the establishment shall be responsible for setting aside a part of its retained surplus balance amount for the affiliated establishments. The provincial-level Departments of Health shall assume the prime responsibility for, and coordinate with the provincial social security agencies in, guiding the setting aside of the surplus balance for each affiliated establishment in conformity with the actual conditions of each locality.
7. In case the allocated capitation fund is fewer than the expense for health insurance-covered medical care within the capitation (or the establishment overspends the capitation fund), the establishment shall balance within its own revenues according to regulations.
Chapter IV
CAPITATION PERFORMANCE MONITORING INDEX
Article 12. Regulations on the rate of inpatient treatment
1. The rate of inpatient treatment shall be determined according to the following formula:
The rate of inpatient treatment | = | The number of inpatient treatments of the year (n) of the establishment |
The number of conversion cards of the year (n) of the establishment |
For an establishment at provincial or central level, the number of inpatient treatments shall only include cases where patients have registered for health insurance-covered initial medical care at the establishment.
In case the establishment making payments by the capitation method has the rate of admission for inpatient treatment of the year of fund allocation that exceeds the one of the preceding year, for each exceeding time, an amount corresponding to the average cost of a health insurance-covered inpatient treatment of the establishment shall be reduced.
2. The number of excessive inpatient treatment shall be calculated according to the following formula:
Article 13. Regulations on the rates of multi-line and referral
1. The rate of multi-line of patients registering for health insurance-covered initial medical care (hereinafter referred to as the multi-line rate for short) at an establishment in a year (n) equals (=) the number of health insurance-covered medical care of health insurance card holders registering for initial medical care at the health insurance-covered medical care provider within the capitation at another establishment (excluding cases of getting health insurance-covered medical care at district-level establishments in the province) of the year (n) divided (:) by the number of conversion cards of the year (n) of the establishment.
The excessive number of multi-line in comparison with the rate of multi-line of the preceding year shall be calculated according to the following formula:
In case the establishment making payments by the capitation method has the rate of multi-line in the year of fund allocation that exceeds the one of the preceding year, for each exceeding time, an amount corresponding to the average cost of an health insurance-covered outpatient medical care of the establishment within the capitation of multi-line cases in the year of fund allocation of the establishment shall be reduced.
2. The rate of referral of multi-line patients to the establishment of the year (n) shall be calculated according to the following formula:
The rate of referral of multi-line patients to the the establishment of the year (n) | = | The number of medical visits of multi-line patients to the establishment continuing to be transferred to provincial- and central-level establishments for the health insurance-covered outpatient medical care within the capitation of the year (n) |
The number of multi-line patients of the year (n) of the establishment |
In which:
For provincial- and central-level establishments, not to apply the referral rate of multi-line patients.
In case the establishment making payments by the capitation method has the referral rate in the year of fund allocation that exceeds the one of the preceding year, for each exceeding time, an amount corresponding to the average cost of an health insurance-covered outpatient medical care of the establishment within the capitation of cases of referral in the year of fund allocation of the establishment shall be reduced.
3. Establishments that receive patients getting health insurance-covered medical care that are transferred from other establishments, when transferring data to the health insurance assessment information system, must have sufficient information related to the code of medical care providers that have transferred the patients to (MA-NOI-CHUYEN) as prescribed in Table 1 of the Appendix issued together with the Decision No. 4210/QD-BYT dated September 20, 2017 of the Ministry of Health on providing for standards and formats of output data used in management, assessment and payment for health insurance-covered outpatient medical care costs. An application for health insurance payment for a case of patient referral to the appropriate level without code of the medical care provider that has transferred the patient shall be not considered as the case of patient referral to the appropriate level and the payment in such case shall comply with current regulations applied for cases of patient referral to inappropriate levels.
Chapter V
IMPLEMENTATION PROVISIONS
Article 14. Effect
This Circular takes effect on July 01, 2021.
Article 15. Transitional provisions and implementation roadmap
1. The capitation fund in 2021 shall be calculated from January 1, 2021, in which the figures used for calculating the capitation fund in 2021 shall comply with the following regulations:
a) The number of equivalent cards of an establishment, province due to the increase or decrease of the number of conversion cards shall be determined according to the difference in the number of conversion cards between the years 2021 and 2019;
b) The total national capitation fund in 2021 as prescribed in Clause 1, Article 4 of this Circular shall be calculated according to the following formula:
In which:
- CP means the expenses for health insurance-covered medical care within the capitation in 2019 to be settled according to the Government’s Decree No. 146/2018/ND-CP dated October 17, 2018 on detailing, and guiding measures to implement, a number of articles of the Law on Health Insurance (hereinafter referred to as the Decree No. 146/2018/ND-CP);
- TL means the rate of health insurance-covered medical care costs within the capitation in the total expenses for health insurance-covered medical care under the payment responsibility of the social security agencies in 2019.
c) T_BHTT of the preceding year is equal to T_BHTT in 2019;
d) T_TTĐS of the preceding year is equal to T_BHTT in 2019;
dd) Indexes of monitoring of establishments shall be determined according to the figures in 2019, in which:
- The multi-line rate, transfer rate of the preceding year shall be equal to the rate multi-line rate, transfer rate in 2019;
- The rate of admission for inpatient treatment of the preceding year equals (=) the number of health insurance-covered medical care within the capitation in 2019 of the establishment divided (:) by the number of health insurance-covered medical care (including inpatient and outpatient treatment) in 2019 of the establishment.
2. Roadmap of implementation for the rate of application of the cost coefficient:
a) The year of 2021: the rate of application of the cost coefficient shall be 80% (eighty percent);
b) From the year of 2022 onwards: To comply with the notice of the Ministry of Health. In case of failure to notify, to continue to apply the rate of application of the cost coefficient of the preceding year.
Article 16. Terms of reference
In case the documents referenced in this Circular are replaced or amended or supplemented, the replacing or amending or supplementing documents shall be applied.
Article 17. Implementation responsibility
1. Responsibilities of the Ministry of Health:
a) Before allocating the capitation fund to the provinces, to check and compare the results of calculation of the national capitation fund, indexes, fund allocation coefficient, and other coefficients related to the allocation of the capitation fund of the Viet Nam Social Security for provinces, based on actually used data;
b) To issue regulations and notification of coefficient k3province;
c) To assume the prime responsibility for, and coordinate with the Viet Nam Social Security in, calculating the health insurance-covered medical care costs within the capitation when there arises an impact of policies related to the payment and settlement of health insurance-covered outpatient medical care costs;
d) To direct establishments to strictly implement professional regulations and synchronously implement measures to ensure the rational, safe and effective use of the capitation fund;
dd) To organize the implementation, examination, inspection, supervision, assessment and summation of the implementation, of this Circular nationwide.
2. Responsibilities of the Viet Nam Social Security:
a) To assume the prime responsibility for calculating the national capitation fund, the conversion coefficient, the fund allocation coefficient, and other coefficients related to the allocation and assignment of the capitation fund of the provinces; reach an agreement with the Ministry of Health before notifying the capitation fund to the provinces;
b) To provide the Ministry of Health with data used for calculation, method of calculation, allocation and assignment of capitation funds for inspection and comparison;
c) In case the total expenses within the national capitation fund in the year of fund allocation are greater than the total allocated national capitation fund, the Vietnam Social Security shall summarize and report according to Clause 6, Article 25 of the Decree No. 146/2018/ND-CP;
d) To notify the capitation funds to the provinces;
dd) To direct provincial social security agencies:
- To implement the method of capitation payment prescribed and guided in this Circular;
- To assume the prime responsibility for, and coordinate with the provincial-level Departments of Health in, determining indexes: the number of health insurance cards of registration for initial medical care, card conversion coefficient, basic charges of provinces, fund allocation coefficient of each establishment and other relevant coefficients according to the guidance of the Ministry of Health and the Vietnam Social Security;
- To coordinate with health insurance-covered medical care providers in the implementation of this Circular;
- To coordinate with the provincial-level Departments of Health in inspecting, supervising and ensuring the benefits of health insurance card holders, supervising the implementation of this Circular for health establishments that carry out the capitation payment, solving problems arising in the process of implementation under their competence;
- To coordinate with the provincial-level Departments of Health in guiding establishments that sign contracts of medical care by capitation method, to handle the surplus balance or overspend of the capitation fund (if any) for their affiliated establishments.
e) To develop an assessment method suitable to the capitation payment method, guide provincial social security agencies to implement and examine, supervise and ensure the benefits of health insurance card holders.
3. Responsibilities of provincial-level People’s Committees:
To direct and promptly solve difficulties and problems within their duties and powers during the implementation of policies and laws on health insurance and contents related to this Circular.
4. Responsibilities of provincial-level Departments of Health:
a) To direct the health insurance-covered medical care providers in the localities to organize the implementation of this Circular;
b) Before allocating the capitation fund to establishments, to check and compare the results of calculation of the capitation funds of the provinces, indexes and the allocation of the capitation fund of the provincial social security agencies for establishments, based on actually used data;
c) To coordinate with the provincial social security agencies in, determining indexes: the number of health insurance cards of registration for health insurance-covered initial medical care, card conversion coefficient, basic charges of provinces, fund allocation coefficients of health establishments and other relevant coefficients according to the guidance of the Ministry of Health;
d) To assume the prime responsibility for, and coordinate with the provincial social security agencies in, directing health establishments to organize the implementation of this Circular at their general clinics and commune-level health stations under the establishments;
dd) To coordinate with the provincial social security agencies in inspecting, supervising and ensuring the benefits of health insurance card holders, supervising the implementation of this Circular for health establishments that carry out the capitation payment, solving problems arising in the process of implementation under their competence;
e) To assume the prime responsibility for, and coordinate with the provincial social security agencies in, guiding establishments that sign contracts of medical care by capitation method to handle the surplus balance or overspend of the capitation funds (if any) for their affiliated establishments in conformity with the situation of localities.
5. Responsibilities of health establishments:
a) To direct units and individuals under their management to research and organize the implementation of this Circular;
b) To ensure the interests of health insurance-paid patients, provide adequately and promptly medicines, chemicals and medical supplies within the scope of benefits of the insured;
c) In case the capitation fund balance exceeds 25% (twenty five percent) of the capitation funds that are temporarily allocated at the beginning of a year, the establishments must send a written explanation to the provincial-level Departments of Health and provincial social security agencies. The provincial-level Departments of Health and provincial social security agencies shall organize an assessment to assess the quality of treatment in order to ensure the interests of the insured;
d) To encode, extract and transfer electronic data related to the implementation of the capitation payment according to regulations;
dd) To handle the surplus balance or overspend of the capitation fund under the guidance of the provincial-level Departments of Health;
e) To allocate funds to their affiliated establishments that do not exceed the total amount of assigned capital funds of the establishments;
g) Actively to use the funds determined in a year to provide medical services to health insurance card holders.
Any problem arising in the course of implementation should be promptly reported to the Ministry of Health (the Planning and Finance Department) for reviewing and handling./.
| FOR THE MINISTER
THE DEPUTY MINISTER Tran Van Thuan |
* All Appendices are not translated herein.
Vietnamese
Circular 04/2021/TT-BYT DOC (Word)
Circular 04/2021/TT-BYT PDF (Original)
