Thông tư 27/2018/TT-BYT hướng dẫn thực hiện BHYT, khám bệnh, chữa bệnh BHYT liên quan đến HIV/AIDS

THE MINISTRY OF HEALTH 

Circular No. 27/2018/TT-BYT dated October 26, 2018 of the Ministry of Health providing guidance on health insurance and provision of covered medical services for people with HIV/AIDS

Pursuant to the Law on Health Insurance No. 25/2008/QH12 dated November 14, 2008, as amended and supplemented by the Law on Health Insurance dated June 13, 2014;

Pursuant to the Law on HIV/AIDS prevention and control No. 64/2006/QH11 dated June 29, 2006;

Pursuant to the Government’s Decree No. 146/2018/ND-CP dated October 17, 2018 elaborating and providing guidance on measures to implement certain Articles of the Law on Health Insurance;

Pursuant to the Government’s Decree No. 75/2017/ND-CP dated June 20, 2017 on defining functions, tasks, powers and organizational structure of the Ministry of Health;

The Minister of Health promulgates a Circular providing guidance on health insurance and provision of covered medical services for people with HIV/AIDS.

Article 1. Scope of adjustment and subjects of application

1.This Circular provides regulations on:

a) Preparation of the list of HIV-positive people eligible to participate in health insurance, and payment of health insurance contributions;

b) Health insurance coverage;

c) Covered medical services, payment of costs of covered medical services, and other healthcare services related HIV/AIDS.

2.This Circular applies to regulatory authorities, organizations and individuals involved in provision of health insurance and covered medical services for HIV-positive people.

Article 2. Preparation of the list of HIV-positive people eligible to participate in health insurance, and payment of health insurance contributions

HIV-positive people are eligible to participate in health insurance in accordance with applicable regulations of the law on health insurance. Listing, payment of insurance contributions, and issuance of health insurance cards to the entities prescribed in Clause 4 and Clause 5 Article 12 of the Law on Health Insurance No. 25/2008/QH12 dated November 14, 2008, as amended and supplemented by the Law on Health Insurance dated June 13, 2014 shall be performed as follows:

1.With respect to HIV-infected patients receiving HIV/AIDS treatment at the health facilities that have the function to provide HIV/AIDS treatment (hereinafter referred to as "HIV/AIDS treatment facilities”) for the first time or people who are found by HIV/AIDS treatment facilities to be HIV-positive:

a) If HIV-infected patients do not yet have health insurance cards whose holders shall have their insurance contributions supported by State budget: The HIV/AIDS treatment facility shall instruct HIV-infected patients to carry out procedures for applying for health insurance cards, and make and submit the list of such HIV-infected patients to the Provincial HIV/AIDS Prevention and Control Office, that shall prepare the list of HIV-infected patients eligible to receive state budget’s health insurance contribution support, at least 05 business days before the last day of the relevant month. Listing HIV-infected patients who receive HIV treatment or are found by the HIV/AIDS treatment facility to be HIV-positive within 05 days before the last day of a month shall be made in the following month.

b) If HIV-infected patients have unexpired health insurance cards, are receiving HIV treatment from HIV/AIDS treatment facilities of an appropriate level and eligible to receive State budget’s health insurance contribution support: The HIV/AIDS treatment facility shall prepare and submit the list of HIV-infected patients participating in health insurance to the Provincial HIV/AIDS Prevention and Control Office at least 30 days before the expiry dates of their health insurance cards;

c) If HIV-infected patients have unexpired health insurance cards, are receiving HIV treatment from HIV/AIDS treatment facilities of an inappropriate level and eligible to receive state budget’s health insurance contribution support: After the health insurance card expires, the HIV/AIDS treatment facility shall introduce the HIV-infected patient who holds that expired health insurance card to the HIV/AIDS treatment facility of an appropriate level which shall take charge of preparing the list of HIV-infected patients eligible to receive state budget’s health insurance contribution support under provisions in Point a of this Clause;

d) By the 15thof each month, the Provincial HIV/AIDS Prevention and Control Office shall consolidate lists of HIV-infected patients eligible to receive State budget’s health insurance contribution support submitted by local HIV/AIDS treatment facilities (including health facilities affiliated to the Ministry of Health and other ministries), and send the consolidated list to the Provincial Social Insurance Office;

dd) Within 10 business days from the receipt of the list from the Provincial HIV/AIDS Prevention and Control Office, the Provincial Social Insurance Office shall review and check it so as to avoid the issuance of more than one health insurance card to a person, and provide information about the participation in health insurance of each listed person;

e) Based on the information provided by the Provincial Social Insurance Office and the support rates for each group of beneficiaries annually approved by the Provincial People s Committee, the Provincial HIV/AIDS Prevention and Control Office shall:

-Prepare the list of HIV-infected patients whose health insurance contributions are supported by funding under its management (if any) and the list of HIV-infected patients requiring health insurance contribution support from local-government budget in which each HIV-infected patient’s health insurance contribution is wholly or partially supported must be specified, and send the prepared lists to the Provincial Department of Health;

-Prepare the list of HIV-infected patients whose health insurance contributions are partially supported (if any) in which the health insurance contribution amount paid by each patient must be specified, and send it to the HIV/AIDS treatment facility where the patient receives HIV treatment.

g) After receiving the list from the Provincial HIV/AIDS Prevention and Control Office, the Provincial Department of Health shall transfer the funding used to give health insurance contribution support as approved to the Social Insurance Office for issuing health insurance cards to these patients by the 10thof the first month of each quarter.

h) Each HIV/AIDS treatment facility shall:

-Inform the relevant HIV-infected patient of, and collect and transfer the health insurance contribution amount payable by that patient (if any) to the Social Insurance Office issuing health insurance card;

-Provide the list of HIV-infected patients participating in health insurance for and inform the Provincial HIV/AIDS Prevention and Control Office of funding for giving health insurance contribution support in writing;

-Receive and transfer photos provided by HIV-infected patients who fail to provide personal identity papers or certificates of personal identification to the Social Insurance Office for issuing photo health insurance cards.

2.HIV-infected patients other than those prescribed in Clause 1 of this Article shall themselves pay health insurance contributions in the family-based form in accordance with Clause 7 Article 9 of the Government’s Decree No. 146/2018/ND-CP dated October 17, 2018. Any relief or reduction in the health insurance contribution rate shall be granted in accordance with applicable Law on Health Insurance.

Article 3. Health insurance coverage

1.When using HIV/AIDS healthcare or treatment services, HIV-infected patients participating in health insurance and other health insurance policyholders shall be eligible to be entitled to interests according to health insurance coverage scope and interests defined by the law on health insurance (unless a health insurance policyholder has received interests from other legal sources of finance).

2.When using HIV/AIDS-related medical services, HIV-infected patients participating in health insurance shall have the costs of the following covered by the health insurance fund:

a) Antiretroviral drugs (unless this cost has been already covered by other legal sources of finance);

b) HIV testing for women who are in pregnant or childbirth performed at the professional request in case costs of such tests are not covered by any other sources of finance;

c) Abortion on HIV-infected women;

d) HIV diagnosis and testing, ARV and other HIV/AIDS-related medical services for children of HIV-infected women;

dd) HIV testing required in medical examination and treatment;

e) HIV testing and treatment with ARV for HIV-exposed people, people accidentally infected with HIV (excluding costs of these services provided for people infected with HIV due to occupational accidents, which have been covered by the state budget);

g) Preventive treatment for opportunistic infections.

Article 4. Covered medical services and payment of costs thereof

1.HIV-infected patients having unexpired health insurance cards shall carry out procedures for registration for medical services covered by health insurance in accordance with the Circular No. 40/2015/TT-BYT dated November 16, 2015 by the Ministry of Health.

If a HIV-infected patient has a health insurance card which is valid within a province and is receiving HIV treatment with ARV at a provincial-level health facility which also provides primary medical services covered by health insurance, that patient may register for primary medical services covered by health insurance at that health facility.

2.If a patient is receiving treatment for HIV/AIDS but gets another disease which cannot be treated by the health facility that he/she is receiving treatment, he/she may apply for referral to another appropriate health facility as regulated.

3.If a HIV-infected patient is receiving treatment for HIV with using ARV but goes on a business trip, works on the move or takes a full-time training program in another province for a period longer than the prescribed period of outpatient treatment by ARV or takes up a temporary residence in another province, he/she is entitled to receive medical services at a health facility that has the level equivalent to the level of the health facility inscribed on his/her health insurance card and also provides treatment for HIV/AIDS; if a health facility at the level equivalent to the level of the health facility inscribed on his/her health insurance card is unable to treat for HIV/AIDS, he/she is entitled to receive treatment at a district-level health facility that provides treatment for HIV/AIDS or apply for referral to an appropriate health facility as regulated.

E.g.: If the registered health facility providing primary medical services covered by health insurance inscribed on the health insurance card of a policyholder is the General Hospital of District A, he/she is entitled to receive covered medical services or treatment for HIV/AIDS at the General Hospital of District B (of the same or another province), or the registered health facility providing primary medical services covered by health insurance inscribed on the health insurance card of a policyholder is the General Hospital of Province C, he/she is entitled to receive covered medical services or treatment for HIV/AIDS at the General Hospital of Province D.

4.If a health facility is unable to perform testing or provide other healthcare services and has to refer a patient or send a pathology specimen to another health facility accredited by a competent authority to render these services, the health insurance fund shall pay costs incurred from performing medical services according to prices of these services and health insurance coverage of the policyholder; the health facility referring the patient or sending pathology specimen shall be responsible for paying costs incurred by the receiving health facility or the testing facility, and then entering these costs into the patient’s medical costs as a basis for making payment arrangements with the Social Insurance Office.

Article 5. Implementation organization

1.Each Provincial Department of Health shall:

a) Direct affiliated health facilities to perform activities prescribed in this Circular; assign commune-level medical stations and relevant health facilities to prepare lists of HIV-infected patients and collect health insurance contributions payable by patients (if any) as regulated in Clause 1 Article 2 hereof, and then transfer them to the Provincial HIV/AIDS Prevention and Control Office for consolidating and submitting the consolidated reports thereof to the Provincial Department of Health for requesting the Social Insurance Office to issue health insurance cards;

b) Preside over and cooperate with Provincial Social Insurance Office to review and compare the list of HIV-infected patients awarded health insurance cards as prescribed in Clause 1 Article 2 hereof, and determine supported amounts to cover costs of issuing health insurance cards;

c) Preside over and cooperate with the Provincial Social Insurance Office to provide guidance on registration for primary medical services covered by health insurance for policyholders infected with HIV;

d) Provide advice for Provincial People’s Committee and People s Council about health insurance contribution supports given to local HIV-infected people do not have health insurance cards;

dd) Cooperate with relevant authorities and organizations to make the estimate of health insurance contribution supports given to HIV-infected people, and submit it to a competent authority of appropriate level as regulated by the Law on State Budget; disseminate information about State budget’s health insurance contribution supports given to HIV-infected people, methods of participating in health insurance, and instruct HIV-infected people participating in health insurance to comply with regulations of the law on health insurance and the law on HIV/AIDS prevention and control.

2.Vietnam Social Security Authority shall organize the implementation of this Circular, and instruct Provincial Social Insurance Offices to:

a) Sign health insurance-covered medical service contracts with health facilities that have the function to treat for HIV/AIDS and are qualified to provide covered medical services as regulated by the Law on Health Insurance to provide medical services and pay costs of HIV/AIDS treatment for HIV-infected patients and other policyholders when using HIV/AIDS-related healthcare and treatment services under provisions in Article 3 hereof and relevant regulations of the law on health insurance;

b) Instruct health facilities to update information about costs of medical services covered by social insurance offices in case the treatment or drug delivery requires results of HIV viral load and CD4 count tests on the health insurance assessment portal so as to ensure accurate information and uninterrupted provision of medicines for patients;

c) Preside over and cooperate with Provincial Departments of Health to review and compare the list of HIV-infected patients for issuing health insurance cards as regulated in Clause 1 Article 2 hereof;

d) Instruct HIV/AIDS treatment facilities to collect costs of health insurance cards paid by HIV-infected people.

3.HIV/AIDS treatment facilities prescribed in Clause 1 Article 2 hereof shall:

a) Provide health insurance-covered medical services for HIV-infected people and other policyholders when using HIV/AIDS-related medical services, ensuring the benefits of policyholders as regulated;

b) HIV/AIDS treatment facilities shall instruct HIV-infected patients to select hospitals or district-level medical centers which have the function to provide treatment for HIV/AIDS in a province as their registered health facilities providing primary covered medical services in accordance with Article 8 of the Circular No. 40/2015/TT-BYT dated November 16, 2015.

E.g.: If a person is founded by the health facility A to be HIV positive but does not have a valid health insurance card, the health facility A shall include that patient in the list of HIV-infected persons applying for health insurance cards and give advice to him/her to select the health facility A as his/her registered health facility providing primary medical services covered by health insurance. In case the patient wishes to register for medical services covered by health insurance at a hospital or a district-level medical center located in District B of the same province, the health facility A shall also include that patient in the list of HIV-infected persons applying for health insurance cards in which the patient’s registered health facility providing primary medical services covered by health insurance as the health facility B must be specified. If that hospital or district-level medical center located in District B does not provide treatment for HIV/AIDS, that HIV-infected patient is still entitled to receive treatment for HIV/AIDS from the health facility A.

c) Cooperate with social insurance offices to make settlement of costs of covered medical services in accordance with applicable regulations of the law on health insurance and this Circular.

4.HIV/AIDS treatment facilities that meet eligibility requirements defined in the law on medical examination and treatment shall request social insurance offices to enter into contracts to provide covered medical services for patients with HIV/AIDS and make settlement of costs thereof.

Article 6. Transition provisions

A policyholder who has been receiving treatment for HIV/AIDS with using ARV at a provincial- or central-level health facility since before the effective date of this Circular is allowed to continue receiving HIV/AIDS treatment from that provincial- or central-level health facility until December 31, 2019 inclusively. In this case, the relevant health facility shall manage and provide treatment for the patient and the patient must not annually carry out procedures for referral for HIV/AIDS treatment.

Article 7. Effect

1.This Circular takes effect on January 01, 2019.

2.The Circular No. 15/2015/TT-BYT dated June 26, 2015 of the Ministry of Health guiding the medical examination and treatment by health insurance for HIV-Positive people and people using HIV/AIDS related health care services shall be abrogated from the effective date of this Circular.

Difficulties that arise during the implementation of this Circular should be promptly reported to the Ministry of Health for consideration./.

For the Minister

The Deputy Minister

Pham Le Tuan