Decree 02/2025/ND-CP amend Decree 146/2018/ND-CP detail Law on Health Insurance

DECREE

Amending and supplementing a number of articles of 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, which has a number of articles amended and supplemented under the Government's Decree No. 75/2023/ND-CP dated October 19, 2023

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Pursuant to the Law on Organization of the Government dated June 19, 2015, and the Law Amending and Supplementing a Number of Articles of the Law on Organization of the Government and the Law on Organization of Local Administration dated November 22, 2019;

Pursuant to the Law on Health Insurance dated November 14, 2008; the Law Amending and Supplementing a Number of Articles of the Law on Health Insurance dated June 13, 2014, and the Law Amending and Supplementing a Number of Articles of the Law on Health Insurance dated November 27, 2024;

At the proposal of the Minister of Health;

The Government hereby promulgate the Decree amending and supplementing a number of articles of 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, which has a number of articles amended and supplemented under the Government's Decree No. 75/2023/ND-CP dated October 19, 2023.

Article 1. Amending and supplementing a number of articles of 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, which has a number of articles amended and supplemented under the Government's Decree No. 75/2023/ND-CP dated October 19, 2023

1. To amend and supplement Article 14 of 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, which was amended and supplemented under Clause 5, Article 1 of the Government's Decree No. 75/2023/ND-CP dated October 19, 2023, as follows:

“Article 14. Health insurance benefit levels for the persons defined in Clauses 1 and 7, Article 22 of the Law on Health Insurance

1. The insured specified in Clauses 3, 4, 5, 8, 9, 11, 17 and 20, Article 3 of this Decree shall be entitled to 100% of the costs of medical care as prescribed at Point a, Clause 1, Article 22 of the Law on Health Insurance.

2. The insured entitled to 100% of the costs of medical care as prescribed at Point a, Clause 1, Article 22 of the Law on Health Insurance, without applying the payment rates under Point c, Clause 2, Article 21 of the Law on Health Insurance include:

a) Revolutionary activists before January 1, 1945;

b) Revolutionary activists between January 1, 1945, and the August 1945 Uprising date;

c) Vietnamese heroic mothers;

d) War invalids, persons entitled to policies like war invalids, grade-B war invalids, and diseased soldiers suffering a working capacity decrease of 81% or more;

dd) War invalids, persons entitled to policies like war invalids, grade-B war invalids, and diseased soldiers receiving treatment of recurring injuries or diseases;

e) Persons participating in resistance wars and infected with agent orange who suffer a working capacity decrease of 81% or more;

g) Under-6 children.

3. 100% of the costs of medical care, for cases in which the cost of a check-up is below 15% of the base salary.

4. 95% of the costs of medical care, for the persons defined in Clause 1, Article 2; Clauses 12, 18 and 19 Article 3, and Clauses 1, 2 and 5, Article 4, of this Decree.

5. The roadmap for implementation and the benefit rate when using outpatient medical care services at the basic-level health establishments as prescribed at Points e and h, Clause 4, Article 22 of the Law on Health Insurance as follows:

a) From January 1, 2025, when using outpatient medical care services at the basic-level health establishments graded below 50, or temporarily classified as basic level, the insured shall receive 100% of the benefits from the health insurance fund;

b) From July 1, 2026, when using outpatient medical care services at the basic-level health establishments graded 50 to below 70, the insured shall receive 50% of the benefits from the health insurance fund;

c) From July 1, 2026, when using outpatient medical care services at the basic-level health establishments that have been determined as provincial or central level or an equivalent level by competent agencies before January 1, 2025, the insured shall receive 50% of the benefits from the health insurance fund;

d) From July 1, 2026, when using outpatient medical care services at the intensive-level health establishments that have been determined as provincial level or an equivalent level by competent agencies before January 1, 2025, under Point h, Clause 4, Article 22 of the Law on Health Insurance, the insured shall receive 50% of the benefits from the health insurance fund.

6. The cases specified at Point a, Clause 5 of this Article shall be used to determine the co-payment for medical care costs in a year specified at Point d, Clause 1, Article 22 of the Law on Health Insurance.

7. For the insured receiving medical care upon requests:

a) The insured possessing a health insurance card when receiving medical care upon requests shall receive payment within the scope of benefits (if any) from the health insurance fund as prescribed in Article 22 of the Law on Health Insurance. Patients shall pay health establishments the difference between the charges for on-demand medical care services and the payment rates of the health insurance fund;

b) The health establishments shall ensure human resources, professional conditions, medical equipment, and the ability to provide medical care services in accordance with the health insurance medical examination and treatment contract signed with the social security office and publicly disclose the expenses that patients must pay outside the scope of benefits and the level of health insurance benefits, the difference in costs, and must notify patients in advance.

8. In case the insured changes the group of subjects specified in Article 12 of the Law on Health Insurance according to decisions of competent state agencies, leading to a change in the level of health insurance benefits and having to change the health insurance card and information on the health insurance card, the new level of health insurance benefits will be calculated from the time the health insurance card and information on the health insurance card newly issued to the insured are valid for use.”.

2. To amend and supplement Article 15 of Decree No. 146/2018/ND-CP, which was amended and supplemented under Clause 6, Article 1 of Decree No. 75/2023/ND-CP as follows:

“Article 15. Procedures for health insurance-covered medical care specified in Clause 1, Article 28 of the Law on Health Insurance

1. To receive medical care, an insured shall produce information about his/her health insurance cards according to any of the following cases:

a) Health insurance cards or codes; if the card has no photo, he/she shall also produce a photo-stuck personal identification paper such as identity card, citizen’s identity card, identity card certificate, passport, 2-level electronic identification account on VNeID application, or other personal identification papers issued by a competent agency or organization, or a written certification given by the commune-level Public Security agency or another paper certified by the education institution that manages the insured;

b) Information about the health insurance card has been integrated in his/her citizen’s identity card or 2-level electronic identification account on VNeID application.

2. For an under-6 child, only his/her health insurance card is required. If the child has not been granted a health insurance card, an original or copy or extract of his/her birth certificate, an original or copy of his/her birth certification paper or an identity card is required. For a newly born, his/her parent or relative shall sign his/her medical records for certification, or the representative of the health establishment shall sign his/her medical records for certification if the child does not have parent or relative.

3. Pending the re-grant or renewal of his/her health insurance card, or health insurance card information, to receive medical care, an insured shall produce the paper of dossier receipt and appointment for grant, re-grant or renewal of the card, or health insurance card information issued by the social security office or its authorized organization or person according to Form No. 4 in the Appendix to this Decree, and his/her personal identification paper as prescribed at Point a, Clause 1 of this Article.

4. An insured who has donated his/her body organ shall produce his/her health insurance card information mentioned in Clause 1 or 3 of this Article. If such person has not yet been granted a health insurance card, he/she shall produce the hospital discharge paper issued by the health establishments where his/her body organ has been taken, and any of his/her personal identification papers such as  identity card, citizen’s identity card, identity card certificate, passport, 2-level electronic identification account on VNeID application, or other personal identification papers issued by a competent agency or organization. If he/she needs immediate treatment after the donation, the representative of the health establishment where his/her body organ has been taken and the patient or his/her relative shall sign his/her medical records for certification.

5. In case of emergency aid, the insured shall produce the papers prescribed in Clause 1 or Clause 2 or Clause 3 of this Article before the end of treatment.

6. A health establishment or the social security office may not impose any health insurance-covered medical care procedures other than those specified in this Article. If it needs copies of health insurance cards or medical care-related papers of patients to serve management work, it shall photocopy them by itself after obtaining consent from the patients or their guardians, and may not request patients to do so or to pay photocopying costs.”.

3. To amend and supplement Point c, Clause 1, Article 16 of Decree No. 146/2018/ND-CP as follows:

“c) A copy of the classification decision or professional and technical temporary classification decision issued by a competent agency. For the cases specified at Points dd and h, Clause 4, Article 22 of the Law on Health Insurance, and Point c, Clause 5, Article 14 of this Law, copies of the competent agency’s document certifying that such health establishment having its professional-technical line classified before January 1, 2025. Such documents must bear the seal of the health establishment”.

4. To add Point g after Point e, Clause 2, Article 21 of Decree No. 146/2018/ND-CP, which was amended and supplemented under Point d, Clause 7, Article 1 of Decree No. 75/2023/ND-CP as follows:

“g) Agencies competent to classify professional and technical levels specified in Clause 3, Article 90 of the Government's Decree No. 96/2023/ND-CP dated December 30, 2023, detailing a number of articles of the Law on Medical Examination and Treatment, shall publicize the List of classified health establishments and their points on their e-portals, and on the information system on medical examination and treatment management.

Health establishments shall publicize professional and technical classification results and the points on their websites and patient reception areas.”.

5. To amend and supplement Clause 1, Article 26 of Decree No. 146/2018/ND-CP as follows:

“1. The insured specified in Clauses 3, 4, 7, 8, 9 and 11, Article 3 of this Decree who are in emergency cases or under inpatient treatment shall be subject to hospital referral under Article 27 of the Law on Health Insurance.”.

6. To add Clauses 11, 12 and 13 after Clause 10, Article 27 of Decree No. 146/2018/ND-CP as follows:

“11. Private health establishments shall propose to pay for health insurance-covered medical care services  according to the health insurance-covered medical care prices of that technical service as prescribed or approved by the provincial-level People's Council for state health establishments in the province or centrally-run city (province), and shall take responsibility for their proposals and receive payment from the health insurance fund according to the following specific principles:

a) Private intensive-level health establishments shall be paid no higher than the highest health insurance-covered medical care service price of an intensive-level state health establishment in the province or of a basic-level state health establishment in the province in case there is no intensive-level health establishment in the province;

b) Private basic-level health establishments shall be paid no higher than the highest health insurance-covered medical care service price of a basic-level state health establishment in the province;

c) Private primary health establishments shall be paid no higher than the lowest health insurance-covered medical care service price of a basic-level state health establishment in the province;

d) Private health establishments that perform technical services whose list has been approved by competent agencies but whose prices have not been regulated or approved by the provincial-level People's Council for state health establishments in the province shall be paid no higher than the highest health insurance-covered medical care service of a state health establishment with the same professional and technical level in a neighboring province or another province nationwide in the case where the state health establishment in a neighboring province does not have a price for that technical service according to the principles prescribed at Points a, b and c of this Clause.

12. In case where state health establishments perform technical services whose list has been approved by competent agencies but whose prices have not been regulated or approved by the competent agencies, such establishments shall be paid no higher than the highest health insurance-covered medical care service of a state health establishment with the same professional and technical level in a neighboring province or another province nationwide if the state health establishment in a neighboring province does not have a price for that technical service according to the principles prescribed at Points a, b, c and d, Clause 11 of this Article.

13. In case a state health establishment performs a technical service whose list has been approved by a competent agency (except for care services included in the cost of a day of treatment, services that are a stage included in the cost of other services) but the competent agency has not yet regulated or approved the price of technical services for health establishments nationwide, or the technical service has been assigned to perform but due to the progression of the disease or the patient's health condition, it is impossible to continue performing the assigned technique, the health establishment shall be paid for the cost of performing the specific medical care service as follows:

a) Payment according to the actual quantity of drugs and medical equipment within the scope of payment of the health insurance fund used for the patient and the purchase price in accordance with law;

b) Payment of salaries, wages, allowances, contributions and surgical and procedural allowances (if any) at the levels prescribed by the Minister of Health”.

7. To replace the phrases in a number of articles and clauses as follows:

a) To replace the phrase “hospital ranking” with the phrase “professional and technical level” in Clause 2, Article 16 of Decree No. 146/2018/ND-CP;

b) To replace the phrase “line transfer” with the phrase “patient transferal” at Points a and b, Clause 2, Article 26 of Decree No. 146/2018/ND-CP;

c) To replace the phrase “to higher-level health establishments” with the phrase “to health establishments according to professional requirements” at Point b, Clause 2, Article 26 of Decree No. 146/2018/ND-CP;

d) To replace the phrase “treatment-line direction” with the phrase “professional and technical direction” in Clause 7, Article 27 of Decree No. 146/2018/ND-CP;

dd) To replace the phrase “same rank, same line” with the phrase “same professional and technical level” at Point b, Clause 1, Article 21 of Decree No. 146/2018/ND-CP, which was amended and supplemented under Point a, Clause 7, Article 1 of Decree No. 75/2023/ND-CP; Point d, Clause 5, Article 42 of Decree No. 146/2018/ND-CP, which was amended and supplemented under Point c, Clause 10, Article 1 of Decree No. 75/2023/ND-CP;

e) To replace the phrase “district- or equivalent-level health establishment” with the phrase “basic-level health establishment that, before January 1, 2025, has been classified as district level by a competent agency, or basic-level health establishment graded below 50, or temporarily classified as basic level”; to replace the phrase “provincial- or equivalent-level health establishment” with the phrase “basic-level health establishment that, before January 1, 2025, has been classified as provincial level by a competent agency, or basic-level health establishment graded from 50 to below 70”; to replace the phrase “central- or equivalent-level” with the phrase “intensive-level” in Article 30 of Decree No. 146/2018/ND-CP;

g) To replace the phrase “lower-level health establishment” with the phrase “health establishment” in Form No. 7 - Contract for health insurance-covered medical care service provision, to Decree No. 146/2018/ND-CP, which was amended and supplemented under Clause 1, Article 2 of Decree No. 75/2023/ND-CP.

8. To amend and supplement a number of phrases in Form No. 4 - Paper of dossier receipt and appointment for grant, re-grant or renewal of the health insurance card, in the Appendix to Decree No. 146/2018/ND-CP as follows:

a) To replace the phrase “grant, re-grant or renewal of the health insurance card” with the phrase “grant, re-grant or renewal of the health insurance card or information about the health insurance card”;

b) To replace the phrase “re-grant, merge, change, adjust information recorded on the health insurance card” to “re-grant, merge, change, adjust information recorded on the health insurance card or information about the health insurance card”;

c) To replace the phrase “written appointment replacing the health insurance card” with the phrase “written appointment replacing the health insurance card or health insurance card information”;

d) To replace the phrase “people’s identity card” with the phrase “identity or citizen’s identity card”.

Article 2. To annul Form No. 5 - Paper of appointment of the re-examination, and Form No. 6 - Paper of line transfer for health insurance-covered medical care, in the Appendix to Decree No. 146/2018/ND-CP, which was amended and supplemented under Clause 1, Article 2 of Decree No. 75/2023/ND-CP.

Article 3. Effect

This Decree takes effect on January 1, 2025.

Article 4. Transitional provisions

1. Health insurance participants visiting health establishments for medical care before the effective date of this Decree and having their medical care ended from the effective date of this Decree shall receive payment from the health insurance fund within the scope of benefits and benefit levels specified in the Law on Health Insurance, and provisions of Clause 1 of this Decree.

2. Papers of appointment of the re-examination, papers of line transfer for health insurance-covered medical care and papers of dossier receipt and appointment for grant, re-grant or renewal of the health insurance card that are granted before January 1, 2025, and remain valid after January 1, 2025, shall continue to be used until their expiry date.

Article 5. Implementation responsibility

Ministers, heads of ministerial-level agencies, heads of government-attached agencies, chairpersons of People’s Committees of provinces and centrally-run cities, and related organizations and individuals shall implement this Decree.