How will the payment of medical examination and treatment from inappropriate level of hospital be paid in Vietnam?

Specifically, according to this Official Dispatch,when a health insurance policyholder receives medical services from any provincial-level hospital of inappropriate level nationwide, his/her inpatient service costs shall be covered by the health insurance fund with the same scope and rate of health insurance coverage as he/she receives medical services from a hospital of appropriate level. After obtaining the consent from Vietnam Social Security, the Ministry of Health of Vietnam hereby provides guidance on implementation of the said Article 22 as follows:

(1) Reimbursement of costs of medical services in case a health insurance policyholder receives medical services from a district-, provincial- or central-level hospital of inappropriate level and then is requested to use inpatient services:

- The health insurance fund shall make payment according to the coverage rate specified in Clause 3 or Clause 6 Article 22 of the Law on Health Insurance for costs of inpatient services, including examination and treatment services (costs of medical examination, subclinical tests, function examinations, diagnostic imaging, etc.) ordered by physicians or performed at outpatient department or emergency department;

- The health insurance fund shall not reimburse costs of outpatient services in case the health insurance policyholder has completed his/her outpatient treatment but then is requested to receive inpatient treatment or day treatment for the same diagnosis.

(2) Reimbursement of costs of medical services in case a health insurance policyholder receives medical services from a hospital of inappropriate level and is requested to receive day treatment:

- The health insurance fund shall reimburse costs of day treatment in case a health insurance policyholder receives medical services from a central- or provincial-level hospital of inappropriate level and is requested to receive day treatment according to the Circular No. 01/2017/TT-BYT dated March 06, 2017 of the Minister of Health of Vietnam and the Circular No. 01/2019/TT-BYT dated March 01, 2019 of the Minister of Health, and Point a (for a central-level hospital) or Point b Clause 3 and Clause 6 Article 22 of the Law on Health Insurance (for a provincial-level hospital).

- In case a health insurance policyholder is requested to use day treatment at a hospital, he/she shall be treated as an inpatient and shall have his/her day treatment costs reimbursed by the health insurance fund in the same manner as reimbursement of costs of inpatient services prescribed herein.

(3) Coverage rates and encoding of data, recording of costs of medical services in case health insurance policyholders receive medical services from hospitals of inappropriate level as prescribed in Point c Clause 3, Clause 4 and Clause 6 Article 22 of the Law on Health Insurance:

- With regard to health insurance policyholders who receive medical services from district-level hospitals as prescribed in Point c Clause 3 Article 22 of the Law on Health Insurance and from provincial-level hospitals as prescribed in Clause 6 Article 22 of the Law on Health Insurance over the country:

+ In case health insurance policyholders use medical services from district-level hospitals as prescribed in Point c Clause 3 Article 22 of the Law on Health Insurance over the country: They shall have costs of inpatient and outpatient services reimbursed at the same rates as they receive medical services from hospitals of appropriate level;

+ In case health insurance policyholders use medical services from provincial-level hospitals as prescribed in Clause 6 Article 22 of the Law on Health Insurance over the country: They shall have costs of inpatient services reimbursed at the same rates as they receive medical services from hospitals of appropriate level;

+ Health insurance policyholders who use medical services from hospitals of inappropriate level as prescribed in Point a of this Section shall not be entitled to exemption from copayment of medical services as prescribed in Point c Clause 1 Article 22 of the Law on Health Insurance; copayments made by patients when they receive medical services from hospitals of inappropriate level shall not be considered by Vietnam Social Security when issuing certificate of exemption from copayment in the year.

- When a health insurance policyholder who has the registered initial healthcare provider at a commune-level medical station or general clinic or district-level hospital uses medical services from another commune-level medical station or general clinic or district-level hospital within the same province as prescribed in Clause 4 Article 22 of the Law on Health Insurance, he/she shall be considered receiving medical services from a health facility of appropriate level and the term "unrestricted referral" shall used in statistical reports. To be specific:

+ He/she shall have costs of inpatient services reimbursed at the same rates as he/she receives medical services from a health facility of appropriate level;

+ He/she shall be entitled to exemption from copayment of medical services as prescribed in Point c Clause 1 Article 22 of the Law on Health Insurance; copayments made by the patient in this case shall be considered by Vietnam Social Security when issuing certificate of exemption from copayment in the year.

- In case a health insurance policyholder uses medical services at a hospital of inappropriate level and is receiving inpatient treatment but his/her health insurance card has been expired:

+ If the health insurance card is not yet renewed or the effective date of the new health insurance card does not follow the expiry date of the old one: The health insurance fund shall reimburse costs of medical services according to the coverage scope and rate specified in the old health insurance card until the patient is discharged or until the day preceding the effective date of the new health insurance card provided total duration shall not exceed 15 (fifteen) days as prescribed in Clause 9 Article 27 of the Government’s Decree No. 146/2018/ND-CP dated October 17, 2018 on elaboration of the Law on Health Insurance;

+ If there is change in the coverage rate specified in the new health insurance card, the reimbursement of costs incurred from the effective date of the new health insurance card shall be made according to the new coverage rate.

- E.g.:  A health insurance policyholder holds a health insurance card whose code is CN3 (coverage rate: 95%), and receives inpatient services from December 15, 2020; his/her health insurance card of code CN3 expires on December 31, 2020 and he/she participates in health insurance for family households and is issued with a new health insurance card of code GD4 (coverage rate: 80%) which is effective from January 06, 2021; Until January 20, 2021, he/she is discharged from the hospital. In this case, costs of medical services shall be reimbursed by the health insurance fund as follows:

+ Costs of medical services within the scope of health insurance coverage incurred from December 15, 2020 to the end of December 31, 2020: the health insurance fund shall make a payment by multiplying 60% of the sum of costs by 95% of the coverage rate (which is the coverage rate of the health insurance card of code CN3);

+ Costs of medical services within the scope of health insurance coverage incurred from January 01, 2021 to the end of January 05, 2021: the health insurance fund shall make a payment equal to 95% of the sum of costs (which is the coverage rate of the health insurance card of code CN3);

+ Costs of medical services within the scope of health insurance coverage incurred from January 06, 2021 to the end of January 20, 2021: the health insurance fund shall make a payment equal to 80% of the sum of costs (which is the coverage rate of the health insurance card of code GD4).

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