Công văn 296/BHXH-CSYT năm 2021 hướng dẫn quy định tại Điều 22 Luật Bảo hiểm y tế do Bảo hiểm xã hội Việt Nam ban hành

The Ministry of Health issued the Official Dispatch No. 627/BYT-BH on January 27, 2021, guiding the implementation of a number of provisions of Article 22 of the Law on Health Insurance and the Official Dispatch No. 666/BYT-BH dated January 27, 2021 on the correction of point b, Section 3 of the Official Dispatch No. 627/BYT-BH. In order to ensure the uniform implementation, Vietnam Social Security (VSS) has sent the Official Dispatch No. 627/BYT-BH and the Official Dispatch No. 666/BYT-BH, requesting Social Security of provinces to study and cooperate with medical establishments providing insured medical examination and treatment services in implementation and assurance of the interests of participants in the health insurance plan when they take medical services, and in performing the following tasks:

1. Examining the use of extra beds compared to the allowable beds at health care facilities providing health insurance-covered medical services

- If any medical establishment invests in expanding their operational capacity, increasing the number of standard hospital beds, but have not had their operating licenses adjusted yet, it is recommended that they should apply for permission for adjustment in their licenses in accordance with the provisions of Clause 3, Article 44 of the Law on Medical Examination and Treatment No. 40/2009/QH12.

- In case where any medical establishment increases the actual number of hospital beds to the extent of exceeding the approved number of hospital beds to reduce the number of shared beds, they will be responsible for adding the corresponding number of staff members in a timely manner as instructed by the Minister of Health at point c, clause 2 of Directive No. 25/CT-BYT dated December 21, 2020 on continuation in strengthening the management, improving the quality of health care services covered by the health insurance plan and, at the same time, sending the social security agency a written notice of the number of extra beds, reasons for use of extra beds as a basis for assessment and payment of medical expenses under health insurance coverage.

- If any medical establishment fails to comply with the Directive No. 25/CT-BYT, using extra beds when the approved number of hospital beds has not been used at full capacity to the extent of affecting the working or comfort space of medical staff and patients, social insurance agencies of provinces should file a petition to state regulatory authorities to seek their decisions on imposition of sanctions for these violations according to regulations.

2. Several notes on implementation of regulations of Article 22 in the Law on Health Insurance:

2.1. In case where any patient who receives an appointment note for a medical follow-up visit after an out-of-network medical care as prescribed in Clause 3 and 6, Article 22 of the Law on Health Insurance (including the case of receiving further medical care after inpatient medical care), that medical examination or treatment visit with the medical follow-up appointment note will be considered as an out-of-network medical visit.

2.2. In case where any participant in the health insurance plan making an out-of-network medical visit as prescribed in point c of clause 3 and clause 6 of Article 22 in the Law on Health Insurance incurs expenses for an inpatient or outpatient medical visit (only in case of the outpatient medical visit to a district-level hospital) which are 15% less than the base pay and are fully covered by his/her health insurance benefit, the data field No. 17 (MUC HUONG (translated as COVERED BENEFIT)) in Table 2 and Table 3 annexed to the Decision No. 4210/QD-BYT dated September 20, 2017 of the Minister of Health, prescribing formats and standards of output data needed for management, assessment and payment of health insurance-covered costs and expenses, is filled with the value “100”.

2.3. Regarding daylight inpatient beds:

- The number of hospital beds in daylight should fall within the limit on the number of inpatient beds approved by competent authorities.

- Payment and settlement of costs of per-day hospital beds on a quarterly basis must conform to regulations laid down in clause 16, Article 6 in the Circular No. 39/2018/TT-BYT dated November 30, 2018 of the Ministry of Health. For this calculation, total days of inpatient care each quarter (year) of a medical establishment include days spent on inpatient beds or daylight inpatient beds.    

2.4. In order to ensure reasonable and effective use of funds of the health insurance plan, improve a sense of responsibility of medical establishments and participants in the health insurance plan, social security agencies in provinces should request medical establishments providing health insurance-covered medical services in writing to promptly formulate and complete medical diagnosis and treatment instructions that specify standards for eligibility for inpatient care or daylight inpatient care services under the directions of the Minister of Health in the Directive No. 25/CT-BYT.  

Social security agencies in provinces are requested, on their own initiative, to cooperate with medical establishments providing health insurance-covered medical services according to the aforesaid instructions. Should there be any difficulty or issue that arises, they need to send Vietnam Social Security a report to seek their prompt appropriate actions (enclosing the Official Dispatch No. 627/BYT-BH and the Official Dispatch No. 666/BYT-BH)./.

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