Decree No. 105/2014/ND-CP dated November 15, 2014 of the Government detailing and guiding the implementation of a number of articles of the Health Insurance Law

DECREE

Detailing and guiding the implementation of a number of articles of the Health Insurance Law[1]

Pursuant to the December 25, 2001 Law on Organization of the Government;

Pursuant to the November 14, 2008 Health Insurance Law and the June 13, 2014 Law Amending and Supplementing a Number of Articles of the Health Insurance Law;

At the proposal of the Minister of Health,

The Government promulgates the Decree detailing and guiding the implementation of a number of articles of the Health Insurance Law.

Chapter I

THE INSURED, RATES, SUPPORT LEVELS AND
STATE BUDGET FUNDS FOR PAYMENT OF
HEALTH INSURANCE PREMIUMS

Article 1.The insured

In addition to those defined in Clauses 1 thru 5 of amended and supplemented Article 12 of the Health Insurance Law, other insured defined in Clause 6 of amended and supplemented Article 12 of the Health Insurance Law include:

1. Rubber workers who are on monthly allowance under Decision No. 206/CP of May 30, 1979, of the Government Council (now the Government), on policies toward workers in the newly liberated region who used to do hazardous and unhealthy jobs and have stopped working due to old age and poor health and are insured under Clause 2 of amended and supplemented Article 12 of the Health Insurance Law.

2. Members of agriculture, forestry, fisheries and salt production households who have average living standards and are insured under Clause 4 of amended and supplemented Article 12 of the Health Insurance Law.

Article 2.Rates of health insurance premiums

1. From January 1, 2015, the monthly rates of health insurance premium applicable to different categories of the insured shall be:

a/ 4.5% of the monthly salary of employees, for the persons defined at Point a, Clause 1 of amended and supplemented Article 12 of the Health Insurance Law.

For an employee who is on maternal leave under the social insurance law, the monthly rate of health insurance premium shall equal 4.5% of her monthly salary before she takes maternal leave;

An employee who is on sickness leave for 14 days or more in a month under the social insurance law is not required to pay health insurance premiums while still enjoying health insurance benefits;

For an employee who is in custody or detention or is suspended from working and investigated whether he/she violates the law, the monthly rate of health insurance premium shall equal 4.5% of 50% of his/her monthly salary under law. In case a competent authority concludes that the employee did not violate the law, he/she shall retrospectively pay health insurance premiums calculated based on the retrospectively received salary amount;

An employee who attends a training course or goes on a working mission overseas is not required to pay health insurance premiums; the training or working period shall be regarded as the health insurance premium payment period till the date the employee receives a decision of his/her agency or organization receiving him/her back to work;

An employee who is working overseas is not required to pay health insurance premiums; within 60 days after returning to the country, if the employee pays health insurance premiums, the whole period of overseas working and the period from the time he/she returns to the time he/she starts paying health insurance premiums shall be regarded as consecutive periods of health insurance premium payment.

For an employee who is in the period of carrying out procedures to enjoy unemployment allowance under the Employment Law and does not pay health insurance premiums in another category of the insured, this period shall be regarded as a period of health insurance premium payment.

b/ 4.5% of the basic salary, for the persons defined at Point b, Clause 1 of amended and supplemented Article 12 of the Health Insurance Law;

c/ 4.5% of the pension or working capacity loss allowance, for the persons defined at Point a, Clause 2 of amended and supplemented Article 12 of the Health Insurance Law;

d/ 4.5% of the basic salary, for the persons defined at Points b and c, Clause 2 of amended and supplemented Article 12 of the Health Insurance Law, and the persons defined in Clause 1, Article 1 of this Decree;

dd/ 4.5% of the unemployment allowance, for the persons defined at Point d, Clause 2 of amended and supplemented Article 12 of the Health Insurance Law;

e/ 4.5% of the basic salary, for the persons defined at Points b, c, d, dd, e, g, h, i, k, l, m and n, Clause 3; and Clauses 4 and 5, of amended and supplemented Article 12 of the Health Insurance Law, and the persons defined in Clause 2, Article 1 of this Decree.

For a child who turns full 72 months before the new school year starts, his/her health insurance card continues to be valid through September 30 of such year and he/she is not required to pay health insurance premiums.

g/ The rates of health insurance premium applicable to all members of a household under Clause 5 of amended and supplemented Article 12 of the Health Insurance Law are prescribed as follows: 4.5% of the basic salary, for the first member; 70%, 60% and 50%, respectively, of the rate applicable to the first member, for the second, third and fourth members; and 40% of the rate applicable to the first member, for the fifth member onward.

For households with health insurance premiums paid with the state budget support, the reduction rates specified at Point g, Clause 1 of this Article shall not apply.

2. Based on practical conditions, the Ministry of Health shall assume the prime responsibility for, and coordinate with the Ministry of Finance and related agencies and organizations in, submitting to the Government the adjustment of health insurance premium rates in order to balance the health insurance fund.

Article 3.State budget support for payment of health insurance premiums for certain categories of the insured

1. The support levels for payment of health insurance premiums for members of households living just above the poverty line as prescribed at Point a, Clause 4 of amended and supplemented Article 12 of the Health Insurance Law are specified as follows:

a/ The support level equal to 100% of health insurance premiums shall be provided for members of households living just above the poverty line who have just got rid of poverty, for 5 years counting from the time they get rid of poverty. For members of households living just above the poverty line who have got rid of poverty before January 1, 2015, but for just fewer than 5 years up to January 1, 2015, the remaining period eligible for this support is at least 1 year;

b/ The support level equal to 100% of health insurance premiums shall be provided for members of households living just above the poverty line and who are living in poor districts listed in the Government’s Resolution No. 30a/2008/NQ-CP of December 27, 2008, on the support program on fast and sustainable poverty reduction for 61 poor districts, and for districts with high rates of poor households which are eligible for the application of infrastructure investment mechanisms and policies under this Resolution;

c/ The support level equal to at least 70% of health insurance premiums shall be provided for members of other households living just above the poverty line.

2. The support level equal to at least 30% of health insurance premiums shall be provided for pupils and students as prescribed at Point b, Clause 4 of amended and supplemented Article 12 of the Health Insurance Law.

3. The support level equal to at least 30% of health insurance premiums shall be provided for members of agriculture, forestry, fisheries and salt production households who have average living standards under the Prime Minister’s Decision No. 32/2014/QD-TTg of May 27, 2014, and for those defined in Clause 2, Article 1 of this Decree.

4. The People’s Committees of provinces and centrally run cities (below referred to as provincial-level People’s Committees) may, based on their local budget capacity and other lawful funding sources, including an amount representing 20% of the unused funds (if any) for medical care in a year as prescribed in Clause 3 of amended and supplemented Article 35 of the Health Insurance Law, set higher health insurance premium support levels for the persons defined at Point c, Clause 1, and Clauses 2 and 3, of this Article and submit them to provincial-level People’s Councils for decision.

Chapter II

LEVELS OF HEALTH INSURANCE BENEFITS AND
METHODS OF PAYMENT OF HEALTH INSURANCE-COVERED MEDICAL CARE COSTS

Article 4.Levels of health insurance benefits in the cases prescribed in Clauses 1 and 7 of amended and supplemented Article 22 of the Health Insurance Law

1. An insured who receives medical care under Articles 26, 27 and 28 of the Health Insurance Law and Clauses 4 and 5 of amended and supplemented Article 22 of the Health Insurance Law shall have medical care costs covered by the health insurance fund within the scope of benefits at the following levels:

a/ 100% of the costs, for the persons defined at Points d, e, g, h and i, Clause 3 of amended and supplemented Article 12 of the Health Insurance Law;

b/ 100% of the costs and no payment limit for a number of medicines, chemicals, medical supplies and technical services prescribed by the Minister of Health, for persons engaged in revolutionary activities before January 1, 1945; persons engaged in revolutionary activities between January 1, 1945, and the August 1945 uprising date; heroic Vietnamese mothers; war invalids, policy beneficiaries enjoying benefits similar to war invalids, class-B war invalids, and diseased soldiers having lost 81% or more of their working capacity; war invalids, policy beneficiaries enjoying benefits similar to war invalids, class-B war invalids and diseased soldiers when receiving treatment for recurrent injuries or diseases; and under-6 children;

c/ 100% of the costs, at the commune level;

d/ 100% of the costs, in case the cost per time of medical care is below 15% of the basic salary;

dd/ 100% of the costs, for a patient who has paid health insurance premiums for 5 consecutive years, counting from the time he/she starts paying health insurance premiums to the time he/she receives medical care, and has an accumulated amount paid for medical care costs in a year larger than 6 months’ basic salaries, counting from the time of 5 consecutive-year payment of health insurance premiums, except the case in which he/she receives medical care at a health establishment of an improper level;

e/ 95% of the costs, for the persons defined at Point a, Clause 2, Point k, Clause 3, and Point a, Clause 4, of amended and supplemented Article 12 of the Health Insurance Law;

g/ 80% of the costs, for other persons.

2. An insured who receives medical care at a health establishment located in an adjacent area between two provinces or centrally run cities (below referred to as provinces or cities) shall have medical care costs covered by the health insurance fund within the scope of benefits prescribed in Clause 1 of this Article in the following cases:

a/ He/she receives medical care at a commune-level health station, polyclinic or district-level hospital;

b/ He/she is transferred between commune-, district- and provincial-level health establishments.

Chairpersons of provincial-level People’s Committees shall direct provincial-level Health Departments to work with provincial-level Social Insurance agencies in organizing health insurance-covered medical care in adjacent areas under the joint guidance of the Ministry of Health and the Ministry of Finance on health insurance-covered medical care in adjacent areas,

3. Costs of on-demand medical care shall be covered by the health insurance fund within the scope of health insurance benefits prescribed in:

a/ Clause 1, Article 4 of this Decree, for patients who receive medical care under Articles 26, 27 and 28 of the Health Insurance Law and Clauses 4, 5 and 6 of amended and supplemented Article 22 of the Health Insurance Law; patients shall themselves pay medical care costs outside the scope of benefits;

b/ Clause 3 of amended and supplemented Article 22 of the Health Insurance Law, for patients who receive medical care at health establishments of improper levels; patients shall themselves pay the medical care costs outside the scope of benefits.

Article 5.Application of methods of payment of medical care costs under amended and supplemented Article 30 of the Health Insurance Law

1. The rate-based payment method shall apply to health establishments that provide health insurance-covered primary health care services.

2. Service charge- and disease-based payment methods shall apply to:

a/ Health establishments that do not apply the rate-based payment method;

b/ Outside-rate medical services at health insurance-covered health establishments that apply the rate-based payment method;

c/ Medical care costs for patients who are transferred to health insurance-covered health establishments that apply the rate-based payment method.

3. The Ministry of Health shall  assume the prime responsibility for, and coordinate with  the Ministry of Finance in, guiding in detail the application of the payment methods specified in Clauses 1 and 2 of this Article to health establishments as appropriate.

Chapter III

MANAGEMENT AND USE OF THE HEALTH
INSURANCE FUND

Article 6.Distribution and use of the health insurance fund

The total amount of health insurance premiums in a province or city, collected at the rates prescribed in Article 2 of this Decree, shall be distributed and used as follows:

1. Ninety percent (90%) of health insurance premiums reserved for medical care (below referred to as the medical care fund) shall be:

a/ Used for covering the costs within the scope of benefits of the insured under amended and supplemented Article 22 of the Health Insurance Law and Article 4 of this Decree;

b/ Deducted for education institutions within the national education system that satisfy the Ministry of Health-prescribed conditions for purchase of medicines, medical supplies and ordinary medical equipment and instruments for providing primary health care for pupils and students.

The level of deduction shall equal 7% of the total amount of collected health insurance premiums calculated based on the total number of pupils and students who study at the education institutions and pay health insurance premiums (including pupils and students who pay health insurance premiums by other categories of the insured) and the rate applicable to each category of the insured as prescribed in Article 2 of this Decree; or 5% of the total amount of collected health insurance premiums calculated based on the total number of under-6 children at preschools.

In the first month of a school year or training course, Social Insurance agencies shall transfer the above amount to education institutions and include such amount in the settlement of health insurance-covered medical care costs under their management. The education institutions shall use, pay and settle such amount with their superior managing agencies under regulations.

c/ Deducted for agencies, organizations or enterprises that have their own health divisions for providing primary health care for the persons managed by these agencies, organizations or enterprises (except agencies, organizations and enterprises that have their own health divisions and sign contracts on health insurance-covered primary health care with Social Insurance agencies). The level of deduction shall equal 1% of the total amount of health insurance premiums paid by agencies, organizations or enterprises to Social Insurance agencies.

The Ministry of Health and the Ministry of Finance shall guide in detail Points b and c, Clause 1 of this Article regarding the conditions and scale; items; and management, payment and settlement of this funding source.

2. Ten percent (10%) of health insurance premiums reserved for the provision fund and the health insurance fund management expenses, of which at least 5% shall be reserved for the provision fund, specifically as follows:

a/ Total annual expenses for the health insurance fund management shall be decided by the Director General of Vietnam Social Security within its total management expenses approved by the Prime Minister;

b/ The provision fund is the remainder after making deduction for the health insurance fund management expenses.

3. Collected health insurance premiums shall be managed and used as follows:

a/ Social Insurance institutions at all levels under Vietnam Social Security shall directly collect health insurance premiums from different categories of the insured and transfer them to Vietnam Social Security for management under the guidance of Vietnam Social Security;

b/ Vietnam Social Security shall fully and promptly transfer funds to provincial-level Social Insurance agencies for making advance and payment for health insurance-covered medical care costs under regulations.

4. Based on the annual data approved by the Management Council of Vietnam Social Security, the unused funds of provinces and cities that have a collected amount of health insurance premiums reserved for medical care larger than the medical care costs in the year shall be used as follows:

a/ Vietnam Social Security shall account the whole unused funds for medical care in 2014 into the provision fund;

b/ From January 1, 2015, to December 31, 2020, Vietnam Social Security shall account 80% of the unused funds into the provision fund and concurrently notify localities of the amount equal to 20% of the unused funds for medical care for implementation under Point a, Clause 3 of amended and supplemented Article 35 of the Health Insurance Law.

Based on the unused funds permitted to be used in localities, provincial-level Health Departments shall collaborate with provincial-level Finance Departments and Social Insurance institutions in working out plans on the use of such unused funds and submit them to provincial-level People’s Committees for approval and reporting to provincial-level People’s Councils. Based on approval decisions of provincial-level People’s Committees, provincial-level Social Insurance agencies shall transfer the funds to units for implementation.

The receiving units shall manage and use the funds under current regulations and with provincial-level Social Insurance agencies for inclusion in the expense settlements of provincial-level health insurance funds, ensuring properness, effectiveness, publicity and transparency.

c/ From January 1, 2021, Vietnam Social Security shall account the whole unused funds into the provision fund for general balancing.

Article 7.Management and use of the provisions fund

1. The provision fund shall be managed by Vietnam Social Security and used to add funding sources for health insurance-covered medical care for provinces and cities in case the collected amounts of health insurance premiums reserved for medical care under Clause 1, Article 6 of this Decree are insufficient for paying the medical care costs in a year. After receiving written records of annual examination, provincial-level Social Insurance agencies shall report them to Vietnam Social Security for appraisal and addition of the whole difference from the provision fund.

2. In case the provision fund is insufficient for covering medical care costs for provinces and cities under Clause 1 of this Article, Vietnam Social Security shall report to its Management Council a plan to settle the case before reporting it to the Ministry of Health and the Ministry of Finance.

The Ministry of Health shall assume the prime responsibility for, and coordinate with the Ministry of Finance in, submitting to the Government measures to fully and promptly ensure funding sources for health insurance-covered medical care under regulations.

Article 8.Expenses for management of the health insurance fund

1. Regular expenses under law, including:

a/ Specific expenses, including:

- Expense for public information and coordination of public information on health insurance development;

- Expense for activities related to the fund’s collection and spending tasks;

- Expense for coordination of the inspection, examination and supervision of the implementation of health insurance.

b/ Expenses for the operation of social insurance apparatuses serving the management of health insurance funds at all levels.

2. Irregular expenses, including:

a/ Expense for information technology development and modernization;

b/ Expense for scientific research, training, retraining and international cooperation activities related to health insurance.

3. Other expenses under law.

The Ministry of Finance shall guide in detail the contents and levels of expenses specified in this Article.

Article 9.Investment from the health insurance fund

1. The health insurance fund’s temporary idle money amount shall be used for investment in the forms prescribed in the Social Insurance Law.

2. The Management Council of Vietnam Social Security shall decide on, and take responsibility before the Government for, the forms and structure of investment from the health insurance fund at the proposal of Vietnam Social Security.

3. All profits actually earned from annual investments from the health insurance fund shall be added to the provision fund for general balancing.

Article 10.Settlement and financial planning

1. Vietnam Social Security shall make a settlement report of a current year before October 1 of the subsequent year under amended and supplemented Article 32 of the Health Insurance Law.

2. Annually, Vietnam Social Security shall make a financial plan on revenues and expenses of the health insurance fund; and expenses for management of the health insurance fund and investment activities using the temporary idle money amount of the health insurance fund, and submit this plan to its Management Council for approval and reporting to the Ministry of Finance and the Ministry of Health.

The Ministry of Finance shall assume the prime responsibility for, and coordinate with  the Ministry of Health in, considering, summarizing and submitting the assignment of annual financial plans to the Prime Minister for decision.

3. Within 15 days after receiving a Prime Minister’s decision on assignment of financial plans, Vietnam Social Security shall complete the allocation of collection and spending estimates to units for implementation.

Chapter IV

IMPLEMENTATION PROVISIONS

Article 11.Transitional provisions

1. For the insured whose health insurance cards remain valid after the effective date of the Law Amending and Supplementing a Number of Articles of the Health Insurance Law, the scope of their benefits must comply with the Law Amending and Supplementing a Number of Articles of the Health Insurance Law and Article 4 of this Decree.

2. For patients whose health insurance cards expire when they are receiving medical treatment at health establishment, the health insurance fund shall still cover their medical care costs within the scope of their benefits under regulations until they are discharged from hospitals or finish their outpatient treatment periods.

3. For the insured who are hospitalized for medical treatment before January 1, 2015, but are discharged on January 1, 2015, or afterward, the health insurance fund shall cover their medical care costs within the scope of their benefits under the Law Amending and Supplementing a Number of Articles of the Health Insurance Law and Article 4 of this Decree.

4. For the persons defined at Point a, Clause 3 of amended and supplemented Article 12 of the Health Insurance Law who retire, are demobilized, shift to do other jobs or stop working, the period of their service in the people’s army, people’s public security or cipher force shall be regarded as a period of health insurance premium payment.

5. Pupils and students who have paid health insurance premiums for the whole 2014-2015 school year are not required to pay the difference calculated at the rate specified at Point g, Clause 1, Article 2 of this Decree.

6. For education institutions within the national education system for which deductions from the health insurance-covered medical care fund had been made for providing primary health care for pupils and students before January 1, 2015, the Ministry of Finance’s guidance shall apply till the end of the 2014-2015 school year.

Article 12.Effect

This Decree takes effect on January 1, 2015.

The Government’s Decree No. 62/2009ND-CP of July 27, 2009, detailing and guiding the implementation of a number of articles of the Health Insurance Law, ceases to be effective on the effective date of this Decree.

Article 13.Implementation guidance responsibility

1. The Ministry of Health shall assume the prime responsibility for, and coordinate with  the Ministry of Finance in, guiding the implementation of articles and clauses as assigned in this Decree; guiding the payment of health insurance premiums by households; and studying and proposing solutions for realizing universal health insurance.

2. The Ministry of Finance shall balance and allocate central budget funds as support for localities that cannot themselves balance their budgets to ensure funding sources for implementation of the health insurance policy in accordance with this Decree; guide the transfer of part of the funds for management of the health insurance fund to commune-level People’s Committees for making lists of the insured in localities; and guide the implementation of articles and clauses as assigned in this Decree.

3. The Ministry of National Defense and the Ministry of Public Security shall assume the prime responsibility for, and coordinate with the Ministry of Health and the Ministry of Finance in, guiding the implementation of health insurance for the categories of the insured defined at Points a, l and n, Clause 3, and Point b, Clause 4, of amended and supplemented Article 12 of the Health Insurance law.

4. Vietnam Social Security shall determine the monthly accumulated amount in a year for use as a basis for determining the levels of benefits of persons who have paid health insurance premiums for 5 consecutive years or more.

5. The Ministry of Labor, War Invalids and Social Affairs shall study and develop criteria for identifying agriculture, forestry, fisheries and salt production households that have average living standards and submit them to the Prime Minister for promulgation; and guide the making of lists of members of agriculture, forestry, fisheries and salt production households that have average living standards.

6. Other related ministries and sectors shall, within the ambit of their functions, tasks and powers, guide the implementation of this Decree.

Article 14.Implementation responsibility

Ministers, heads of ministerial-level agencies, heads of government-attached agencies and chairpersons of provincial-level People’s Committees shall implement this Decree.-

On behalf of the Government
Prime Minister
NGUYEN TAN DUNG