Nghị định 188/2025/NĐ-CP hướng dẫn Luật Bảo hiểm y tế

DECREE

Providing elaborations of and guidance on certain articles of the Law on Health Insurance

Pursuant to the Law on Government Organization dated February 18, 2025;

Pursuant to Law on Health Insurance dated November 14, 2008; Law on amendments to the Law on Health Insurance of dated June 13, 2014; Law on amendments to the Law on Health Insurance dated November 27, 2024;

Pursuant to Law No. 90/2025/QH15 dated June 25, 2025 amending certain articles of the Law on Procurement, Law on Public-Private Partnership Investment, Law on Customs, Law on Value Added Tax, Law on Import Duties and Export Duties, Law on Investment, Law on Public Investment, Law on Management and Use of Public Property;

Pursuant to Resolution No. 190/2025/QH15 dated February 19, 2025 of the National Assembly providing regulations on handling certain issues related to the reorganization of the state apparatus;

At the request of the Minister of Health;

The Government hereby promulgates a Decree providing elaborations of and guidance on certain articles of the Law on Health Insurance.

Chapter I

GENERAL PROVISIONS

Article 1. Governing scope

This Decree provides elaborations of and guidance on certain Articles of Law on Health Insurance No. 25/2008/QH12 dated November 14, 2008, which has been amended by Law No. 32/2013/QH13, Law No. 46/2014/QH13, Law No. 97/2015/QH13, Law No. 35/2018/QH14, Law No. 68/2020/QH14, Law No. 30/2023/QH15 and Law No. 51/2024/QH15 (hereinafter referred to as “Law on Health Insurance”). To be specific:

1. Elaborations of the following contents:

a) Health insurance provider contracts as prescribed in Article 25 of the Law on Health Insurance;

b) Procedures for health insurance-covered medical care as prescribed in clause 1 Article 28 of the Law on Health Insurance;

c) Methods of payment and the application of methods of payment of health insurance-covered medical care costs as prescribed in Article 30 of the Law on Health Insurance;

d) Payment of health insurance-covered medical care costs as prescribed in points a and b clause 2 and clause 3 Article 31 of the Law on Health Insurance;

dd) Allocation and use of funds in accordance with clause 5 Article 35 of the Law on Health Insurance;

e) Handling of violations of health insurance laws in accordance with point a clause 2, point a clause 3 and clause 4 Article 49 of the Law on Health Insurance.

2. Elaborations of the following:

a) Eligible participants in health insurance as specified in point a clause 7 Article 12 of the Law on Health Insurance;

b) Rates of health insurance premiums and subsidies, responsibility for payment and methods of payment of health insurance as prescribed in points dd and e clause 1 and clause 7 Article 13 of the Law on Health Insurance;

c) Issuance of health insurance cards in electronic and physical forms as prescribed in clause 3 Article 17 of the Law on Health Insurance;

d) Health insurance coverage as specified in points a and c clause 3 Article 21 of the Law on Health Insurance;

dd) Health insurance reimbursement rates of participants in health insurance as prescribed in point b clause 1, points e and h clause 4 Article 22 of the Law on Health Insurance; cases where participants in health insurance using on-demand medical service as prescribed in clause 6 Article 22 of the Law on Health Insurance and other cases not falling under clause 1 Article 22 of the Law on Health Insurance;

e) Conclusion of health insurance provider contracts (hereinafter referred to as "provider contract") as prescribed in Article 24 of the Law on Health Insurance;

g) Payment of health insurance-covered medical care costs as prescribed in point c clause 2 and point a clause 4 Article 31 of the Law on Health Insurance;

h) Management of health insurance funds, decide financial sources designated for the health insurance-covered medical care services in the event of a budget deficit of the health insurance funds as stipulated in Clause 2, Article 34 of the Law on Health Insurance;

i) Expenditures on health insurance organization and operation as prescribed in clause 5 Article 35 of the Law on Health Insurance;

k) Cases falling under clause 1 Article 48b of the Law on Health Insurance not be considered as evasion of health insurance payment if there are legitimate reasons;

l) Transitional provisions applied to the implementation of provider contracts signed before July 1, 2025 and are still valid after July 1, 2025.

3. Guidance on the following:

a) Payment of costs of medicines and medical devices as prescribed in clause 3 Article 55 of the Law on Procurement in 2023 which is amended by Law No. 90/2025/QH15;

b) Application of technical information and digital transformation in implementing health insurance;

c) Duties and powers of ministries, local authorities, agencies and persons having authority over health insurance after the organizational restructuring;

d) Responsibilities of related parties in the implementation.

Article 2. Regulated entities

1. This Decree applies to health insurance participants, health insurance-covered health facilities, social security authorities, other organizations and individuals relating to health insurance, including entities falling under the cases specified in clause 2 of this Article.

2. Health insurance participants, health insurance-covered health facilities in the following cases:

a) Health insurance participants who are under the management of the Ministry of National Defense and the Ministry of Public Security receive medical care at health insurance-covered health facilities that are not under the management of the Ministry of National Defense and the Ministry of Public Security;

b) Health insurance participants who are not under the management of the Ministry of National Defense and the Ministry of Public Security receive medical care at health insurance-covered health facilities that are under the management of the Ministry of National Defense and the Ministry of Public Security.

3. Health insurance participants under the people's army, people's police, and cipher officers receiving medical care at health insurance-covered health facilities that are under the management of the Ministry of National Defense and the Ministry of Public Security shall be governed by the specific regulations of the Government applicable to these entities.

Article 3. Cases not considered evasion of health insurance payment

The cases specified in points a and c clause 1 Article 48b of the Law on Health Insurance will not be considered evasion of health insurance payment when one of the following reasons is provided by the competent authority regarding disaster prevention, state of emergency, civil defense, and epidemic prevention and control, including:

1. Storms, floods, inundation, earthquakes, large-scale fires, prolonged droughts, and other types of natural disasters directly and severely impact production and business operations.

2. Dangerous epidemics that have been announced by competent state agencies, significantly affecting the production and business operations as well as financial capacities of agencies, organizations, and employers.

3. The state of emergency as prescribed by law that unexpectedly impacts the operations of agencies, organizations, and employers.

4. Other force majeure events as prescribed by civil law.

Article 4. Determining the amount payable and reimbursing costs for patients in the case of late payment or evasion of health insurance premiums

1. Any agency, organization, or employer who commits evasion or late payment of health insurance premiums must pay an amount corresponding to the act of late payment or evasion to the social security authority. The amount payable for the act of late payment or evasion of health insurance premiums shall be determined as follows:

Cđt = Pst x n x 0,03%

Of which:

- Cđt: The amount payable for the number of days of late payment or evasion of health insurance premiums for the month t (t = 1, 2, 3, ..., 12)

- Pst: The amount payable arising for the month of t.

- n: The number of days of late payment or evasion.

2. Agencies, organizations, and employers that commit late payment or evasion of health insurance premiums shall reimburse employees for health insurance-covered medical care costs as follows:

a) Employees or their relatives or lawful representatives as per the provisions of law shall directly submit their applications, including all documents specified in Clauses 2, 3, and 4 of Article 55 of this Decree, to their agencies, organizations, or employers that have committed late payment or evasion of health insurance premiums;

b) Agencies, organizations, and employers are responsible for paying the health insurance-covered medical care costs for employees or employees’ relatives or lawful representatives in accordance with laws within 40 days from the date of receipt of satisfactory applications for the payment;

c) A health facility shall provide an itemized statement of costs determining the amount of money the patient has paid to the health facility enclosed with a legal invoice at the request of the patient to serve as a basis for the patient to request reimbursement of health insurance-covered medical care costs.

Chapter II

ELIGIBLE ENTITIES, PREMIUM RATES, RATES OF SUBSIDIZATION, AND RESPONSIBILITY TO PAY HEALTH INSURANCE PREMIUMS

Article 5. Eligible participants in health insurance

Health insurance participants shall include the eligible participants in health insurance as specified in clauses 1, 2, 3, 4, 5 and 6 Article 12 of the Law on Health Insurance and the following persons:

1. Rubber plantation workers who are receiving monthly allowances as prescribed by the Government and participate in group health insurance paid by social security agencies according to Clause 2, Article 12 of the Law on Health Insurance.

2. Residents of liberated communes during the resistance against the French or the Americans who are currently residing in these liberated communes who have had their information updated in the National Population Database and the Residence Database and participate in group health insurance funded by the state budget to cover the entities specified in Clause 3, Article 12 of the Law on Health Insurance.

3. Individuals awarded the title of the people’s artist or excellent artist who are from households whose monthly average income per capita is lower than the statutory pay rate stipulated by the Government but are not the participants specified in Clauses 1, 2, and 3 of Article 12 of the Law on Health Insurance who participate in group health insurance paid by the state budget according to Clause 3 of Article 12 of the Law on Health Insurance.

4. Victims of unexploded ordnance (UXO) and unexploded bombs (UXBs) stipulated in Clause 8 Article 3 of Decree No. 18/2019/ND-CP dated February 1, 2019 of the Government on performing management and taking actions to remedy the consequences of UXO and UXBs who are not the entities specified in Clauses 1, 2, and 3 of Article 12 of the Law on Health Insurance participate in group health insurance subsidized by the state budget to cover the entities stipulated in Clause 4 of Article 12 of the Law on Health Insurance.

5. Relatives of employees engaged in other activities within cryptography organizations as stipulated by the law on cryptography who are not eligible participants in health insurance specified in points a, b, c, d, dd, e, g, h, and i clauses 1, 2, and 3 Article 12 of the Law on Health Insurance participate in group health insurance paid by the employers, employees or both to cover the entities specified in clause 1 Article 12 of the Law on Health Insurance.

6. Individuals participating in the resistance, defending the Fatherland, fulfilling international obligations, and other entities who have their health insurance paid by the state budget in accordance with the regulations set forth in legislative documents issued prior to January 1, 2025 participate in group health insurance funded by the state budget to cover the entities specified in Clause 3, Article 12 of the Law on Health Insurance.

7. Military trainees (recruits) for the commune-level Military Command with a college or university degree in grassroots military education under a full-time program as stipulated by the Prime Minister's decision and regulations of law before January 1, 2025 who are receiving subsistence allowances from the state budget and have not yet participated in health insurance participate in group health insurance funded by the state budget to cover the entities specified in Clause 3, Article 12 of the Law on Health Insurance.

8. Persons specified in clauses 1, 2, 3, 4, 5, 6, and 7 of this Article that are eligible for multiple forms of health insurance participation according to the groups of participants stipulated in Article 12 of the Law on Health Insurance shall participate in health insurance according to the principle delineated in point a, clause 5 of Article 13 of the Law on Health Insurance.

9. Participants specified in clause 4 of this Article and Clause 4 of Article 12 of the Law on Health Insurance have the option to participate in the health insurance with the highest rate of subsidization.

Article 6. Premium rates, rates of subsidies, and responsibility to pay health insurance premiums

1. Rates of premiums paid by employers, employees, or both are regulated as follows:

a) Monthly premium rate for the participants specified in points a, c, d, and e Clause 1 Article 12 of the Law on Health Insurance shall be equal to 4,5% of the monthly salary as the basis for the payment of compulsory social insurance, of which the employer cover two-thirds of the total payment and the employee covers the remaining one-third;

b) Monthly premium rate for the participants specified in points b and dd Clause 1 Article 12 of the Law on Health Insurance shall be equal to 4,5% of the monthly salary as the basis for the payment of compulsory social insurance and shall be paid by such participants;

c) Monthly premium rate for the participants specified in point g Clause 1 Article 12 of the Law on Health Insurance shall be equal to 4,5% of the statutory pay rate, of which the employer cover two-thirds of the total payment and the employee covers the remaining one-third;

d) Monthly premium rate for the participants specified in point h Clause 1 Article 12 of the Law on Health Insurance shall be equal to 4,5% of the monthly salary as the basis for the payment of compulsory social insurance, of which the employer cover two-thirds of the total payment and the employee covers the remaining one-third;

dd) Monthly premium rate for the participants specified in point h Clause 1 Article 12 of the Law on Health Insurance shall be equal to 4,5% of the statutory pay rate and shall be paid by the employers of defense workers and public employees currently serving in the military, as well as by the employers of public security workers currently working in the people’s police;

e) Monthly premium rate for the participants specified in Clause 5 Article 5 of this Decree shall be equal to 4,5% of the statutory pay rate and shall be paid by the employers of employees engaged in other activities within cryptography organizations in accordance with cipher laws;

g) In case employee is an official or public employee who is being detained by the police, suspended from work or suspended from holding a title but have not been disciplined, the monthly premium rate shall be equal to 4,5% of 50% of the monthly salary as the basis for the payment of mandatory social insurance of the employee for the month immediately preceding their temporary detention or suspension in accordance with laws, of which the employer covers two-thirds of the total payment and the employee covers the remaining one-third. In the event that the competent authority concludes that there has been no violation of the law, the employer and the employee are required to retrospectively pay health insurance on the amount of salary that is being retrospectively paid.

2. The premium rates paid by social security authorities are stipulated as follows:

a) The monthly premium rate for the participants stipulated in point a, clause 2, Article 12 of the Law on Health Insurance shall be equal to 4,5% of the pension or loss of earning capacity benefit (LOEC benefit);

b) The monthly premium rate for the participants stipulated in points b and c clause 2, Article 12 of the Law on Health Insurance and clause 1 Article 5 of this Decree shall be equal to 4,5% of the statutory pay rate;

c) The monthly premium rate for the participants stipulated in point d, clause 2, Article 12 of the Law on Health Insurance shall be equal to 4,5% of the unemployment benefits.

3. Premium rates of groups funded by the state budget are stipulated as follows:

a) The monthly premium rate for the participants specified in points e, g, h, i, k, l, m, o, p, q, r, s, t, and u Clause 3 Article 12 of the Law on Health Insurance and Clauses 2, 3, 6, and 7 Article 5 of this Decree shall be equal to 4,5% of the statutory pay rate.

b) The monthly premium rate for the participants specified in point n clause 3 Article 12 of the Law on Health Insurance shall be equal to 4,5% of the statutory pay rate and paid through the agencies, organizations, or units that grant scholarships.

4. Premium rates of groups subsidized by the state budget are stipulated as follows:

The monthly premium rate for the participants specified in clause 4 Article 12 of the Law on Health Insurance and clause 4 Article 5 of this Decree shall be equal to 4,5% of the statutory pay rate and shall be paid by the participants themselves and partially subsidized by the state budget in accordance with clause 6 of this Article.

5. The monthly premium rates for the participants specified in clause 5 Article 12 of the Law on Health Insurance shall be prescribed as follows:

a) The monthly premium rate shall be equal to 4,5% of the statutory pay rate and shall be paid by the participants, whether individually or under a family health plan;

b) Members of a household specified in point a, clause 5, Article 12 of the Law on Health Insurance who participate in health insurance under a family health plan in a fiscal year shall be eligible for the following deductions: The first participant shall pay a premium equal to 4,5% of the statutory pay rate; the second, third, and fourth participants shall pay an amount equal to 70%, 60%, and 50% of the premium paid by the first participant respectively; the premium paid by the fifth person onwards shall be equal to 40% of the premiums paid by the first participant.

6. Rates of subsidization from the state budget are stipulated as follows:

a) 100% of the health insurance premiums shall be subsidized for individuals from near-poor households residing in impoverished communes as per the Decision of the Prime Minister and other legal documents from competent authorities;

b) At least 70% of the health insurance premiums shall be subsidized for the entities specified in point a clause 4 Article 12 of the Law on Health Insurance;

c) At least 70% of the health insurance premiums shall be subsidized for the entities specified in point g clause 4 Article 12 of the Law on Health Insurance. The subsidization period shall be 36 (thirty-six) months from the time when the commune where the individual resides is no longer classified as a disadvantaged area or an extremely disadvantaged area;

d) At least 50% of the health insurance premiums shall be subsidized for the entities specified in point i clause 4 Article 12 of the Law on Health Insurance; The subsidization period shall be 01 year from the time when the participant is certified as a victim by the competent authority in accordance with the provisions of the Law on Prevention and Combat of Human Trafficking;

dd) At least 50% of the health insurance premiums shall be subsidized for the entities specified in points b, c, dd, e and h clause 4 Article 12 of the Law on Health Insurance;

e) At least 30% of the health insurance premiums shall be subsidized for the entities specified in point d clause 4 Article 12 of the Law on Health Insurance and clause 4 Article 5 of this Decree.

Article 7. Methods and responsibility to pay health insurance premiums of some entities

1. For participants who are receiving retirement pensions, loss of earning capacity benefits (LOEC benefits), or monthly social insurance benefits covered by the state budget as stipulated in clause 2, point q of clause 3 of Article 12 of the Law on Health Insurance and clause 1 of Article 5 of this Decree, social security authorities shall monthly transfer the funds for payment of health insurance to these participants from the budget allocated for retirement pensions and social insurance benefits provided by the state budget.

2. For the participants specified in points e, i, and k of Clause 3, Article 12 of the Law on Health Insurance and Clause 6 of Article 5 of this Decree, Departments of Home Affairs shall quarterly transfer the funds for payment of health insurance from the budget allocated for implementing incentive policies for revolutionary contributors into the health insurance fund. Home affair authorities must complete the transfer of funds to the health insurance fund for a year by December 15 of that year.

3. For the participants specified in point r Clause 3, Article 12 of the Law on Health Insurance and Clause 2 of Article 5 of this Decree, Departments of Health shall quarterly transfer the funds for payment of health insurance from the budget allocated for implementing social protection policies into the health insurance fund. Departments of Health must complete the transfer of funds to the health insurance fund for a year by December 15 of that year.

4. For the entities specified in points c, dd, e, h, and i of Clause 4, Article 12 of the Law on Health Insurance and Clause 4, Article 5 of this Decree, the social security authorities shall quarterly consolidate the number of health insurance cards that have been issued and the total premiums and subsidies according to Form No. 1 enclosed with this Decree, and submit the consolidated documents to the Departments of Finance to transfer the funds for payment of health insurance from the local government budgets as stipulated in Clause 10 of this Article.

5. Regarding the entities specified in points g, h, l (excluding the relatives of the entities managed by the Ministry of National Defense), m, o, p, s, t, and u of clause 3, points a and g of clause 4 of Article 12 of the Law on Health Insurance, and clause 3 Article 5 of this Decree:

a) Social security authorities shall consolidate the number of health insurance cards issued and total premiums and subsidies according to Form No. 1 in the Appendix enclosed with this Decree, and submit the consolidated documents to the Departments of Finance to transfer funds to the health insurance fund as prescribed in Clause 10 of this Article.

b) Regarding entities listed annually, the premiums payable shall be calculated from January 1 ^st; regarding additional entities during the year, the premiums payable shall be calculated in accordance with the provisions in clauses 3 and 4 of Article 6 of this Decree. The benefits shall take effect from the date specified in the approval decision.

6. For the students specified in point b, clause 4, Article 12 of the Law on Health Insurance:

a) Students or their parents or guardians, are responsible for paying the health insurance premiums payable by themselves as stipulated in Clause 2, Article 8 of this Decree to the social security authorities every 3, 6 or 12 months;

b) Students who are enrolled in educational institutions or vocational education institutions under ministries or central authorities shall be subsidized by the central government budget. Every 3, 6 or 12 months, social security authorities of provinces or central-affiliated cities shall determine the number of health insurance cards that have been issued and the amount of premiums payable by students, and state subsidies according to Form No. 1 of the Appendix enclosed with this Decree, and submit a condoliated report to the Vietnam Social Security for documentation and onward transmission to the Ministry of Finance for allocation of funds to the health insurance fund.

c) If a student is studying at another school, support will be provided by the local government budget of the province in which the school is located (plus support provided by central government budget, if any), regardless of the student's permanent residence. Every 3, 6 or 12 months, the social security authority shall determine the number of health insurance cards that have been issued and the amount of premiums collected from the students, and state subsidies according to Form No. 1 of the Appendix enclosed with this Decree, and submit the consolidated report to the Department of Finance to transfer the funds to the health insurance fund according to the provisions of clause 10 of this Article.

7. For entities whose health insurance premiums are partially subsidized by the state budget according to the provisions of point d clause 4 Article 12 of the Law on Health Insurance:

a) Representatives of households shall pay the health insurance premiums payable by themselves as stipulated in Clause 2, Article 8 of this Decree to the social security authorities every 3, 6 or 12 months;

b) Every 3, 6 or 12 months, the social security authority shall consolidate the number of health insurance cards that have been issued and the amount of premiums collected from the participants, and state subsidies according to Form No. 1 of the Appendix enclosed with this Decree, and submit the consolidated documents to the Department of Finance to transfer the funds to the health insurance fund according to the provisions of clause 10 of this Article.

8. For an eligible participant under a family health plan as specified in point a clause 5 Article 12 of the Law on Health Insurance: A representative of the household or a member of the household shall pay the health insurance premiums in accordance with the provisions of Clause 3 Article 8 of this Decree to the social security authorities every 3, 6 or 12 months.

9. For entities participating in health insurance as stipulated in points h and i of Clause 1, Article 12 of the Law on Health Insurance and Clause 5, Article 5 of this Decree, the employer shall monthly pay health insurance for these entities along with the health insurance for employees according to the regulations from the following sources:

a) For units that are funded by state budget, they shall be covered by the state budget;

b) For public service providers, the funding of the providers shall be used in accordance with the provisions of law on autonomy mechanism of public service providers;

c) For enterprises, their funding shall be used.

10. The Departments of Finance shall, based on the provisions on hierarchy of management of budgets of competent authorities and the tabular statement of entities, full or partial state subsidies that are transferred by social security authorities, quarterly forward the funds to the health insurance fund. The Departments of Finance must complete the transfer of funds to the health insurance fund for a year by December 15 of that year.

11. For the entities specified in point n clause 3 Article 12 of the Law on Health Insurance, scholarship providers shall pay quarterly health insurance premiums as per regulations to the health insurance fund.

12. For the entities specified in point l clause 3 Article 12 of the Law on Health Insurance who are relatives of entities managed by the Ministry of National Defense and the entities specified in clause 7 Article 5 of this Decree, financial agencies of units affiliated to the Ministry of National Defense shall quarterly pay the health insurance premiums to the Military and Social Security Authority.

13. In the event that a health insurance participant dies, goes missing, or no longer resides in Vietnam, the amount of health insurance premiums will be calculated from the time of payment until the time of cessation of payment as listed in the report on decrease in the number of participants (reduction in payments) prepared by the competent authority.

Article 8. Determining amounts of premiums and subsidies for certain entities when the State adjusts rates of health insurance premium rates and adjusts statutory pay rates

1. For the group of entities specified in Clause 3 of Article 12 of the Law on Health Insurance and those eligible for full subsidization of the health insurance premiums as stipulated in Point a, Clause 6 of Article 6 of this Decree, whose health insurance premiums are fully subsidized by the state budget:

a) Monthly full or partial state subsidy shall be equal to the monthly health insurance premium rate multiplying (x) by the statutory pay rate. When the State adjusts the health insurance premium rate and/or adjusts the statutory pay rate, the full state subsidies shall be changed from the date on which the new health insurance premium rate and the new statutory pay rate are applied.

b) The health insurance premium for the entity specified in point h, clause 3, Article 12 of the Law on Health Insurance shall be calculated within the period from the date of birth until the child reaches 72 months of age. In the case of children who are Vietnamese citizens born abroad, the health insurance premiums shall be calculated within the period from the date the child resides in Vietnam in accordance with the provisions of law.

2. For the group of entities whose health insurance premiums are partially subsidized by the State according to the provisions of points b and d clause 4 Article 12 of the Law on Health Insurance:

a) Monthly premium of a participant and monthly state subsidy shall be equal to the monthly health insurance premium rate multiplying (x) by the statutory pay rate at the time of payment by the health insurance participant.

b) When the State adjusts the health insurance premium rate and/or the statutory pay rate, it is not required to pay any additional premium or refund for the difference arising from the adjustment of health insurance premium and/or statutory pay rate for the remaining period of health insurance coverage for both the participant and the state budget.

3. For the group of health insurance participants specified in clause 5 Article 12 of the Law on Health Insurance:

a) Monthly premium of a participant shall be equal to the monthly health insurance premium rate multiplying (x) by the statutory pay rate at the time of payment;

b) When the State adjusts the health insurance premium rate and/or the statutory pay rate, it is not required to pay any additional premium or refund for the difference arising from the adjustment of health insurance premium and/or statutory pay rate for the remaining period of health insurance coverage for the participant.

4. Individuals participating on specific days of the month will have their health insurance premiums determined on a monthly basis from the day the health insurance is paid.

Chapter III

HEALTH INSURANCE CARDS

Article 9. Compiling a list of eligible participants to be granted health insurance cards

1. The responsibility for compiling a list of eligible participants to be granted health insurance cards shall comply with the provisions of Clause 3, Article 8, and Clause 1, Article 17 of the Law on Health Insurance.

2. Social security authorities shall prepare lists of individuals who have donated body parts in accordance with the law to be granted health insurance cards, based on the hospital discharge notes issued by the health facilities where the body parts were harvested. The health facilities shall provide guidelines for the donors to fully provide information according to Form No. 2 in the Appendix enclosed herewith on the National Public Service Portal or through the application of the social security authority, and provide guidelines for the donors to complete the procedures for issuing health insurance cards as stipulated in Article 11 of this Decree.

3. The Commune-level People's Committee shall formulate a list of the entities specified in clauses 1, 2, 3, 4, and 6 of Article 5 of this Decree, and the entities stipulated in points e, h, i, k, o, r, s, and t of clause 3, and points a, d, and g of clause 4 of Article 12 of the Law on Health Insurance who are currently residing in the community to be granted health insurance cards.

4. Employers shall prepare lists of individuals specified in Clause 5, Article 5 of this Decree to be granted health insurance cards.

5. Facilities for the care and rehabilitation of war veterans and revolutionary contributors and social assistance facilities (hereinafter referred to as “care facilities”) shall compile lists of the entities specified in points e, h, i, k, r, and s of Clause 3, Article 12 of the Law on Health Insurance who are being regularly cared for in the care facilities to be granted health insurance cards.

6. Lists of participants in health insurance shall be compiled using Form No. 3 and Form No. 4 of the Appendix enclosed herewith.

Article 10. Information on health insurance cards

1. A physical or electronic health insurance card shall be issued by a social security authority accompanying the health insurance number and the following basic information:

a) The personal information of the health insurance participant, including: full name, gender, date of birth;

b) Information about the health insurance reimbursement rate according to the health insurance participant;

c) The time when the health insurance card is valid for use;

d) The registered primary care provider;

dd) The time of participating in health insurance for at least 5 consecutive years, for those required to co-pay for medical care.

2. The electronic health insurance card is presented in the form of electronic data created by the Vietnam Social Security using electronic means, which contains information as stipulated in Clause 1 of this Article.

3. The information regarding the health insurance card specified in clause 1 of this Article shall be integrated and synchronized according to the health insurance number and the identification number of the health insurance participant.

Article 11. Procedures for issuance of health insurance cards

1. A social security authority shall issue each health insurance participant an electronic health insurance card. The social security authority shall issue a physical health insurance card each at the request of the health insurance participant.

2. The issuance of health insurance cards (including initial issuance and reissuance) and the adjustment of health insurance card information shall be carried out as follows:

a) The health insurance participant must fully declare information according to Form No. 2 enclosed herewith, or the managing agency or organization must fully declare information according to Form No. 3 enclosed herewith on the National Public Service Portal, or via the social security authority's application, or submit it directly at the one-stop division of the social security authority tasked with reception or send it through public postal services to the social security authority tasked with reception;

b) The health insurance participant or managing agency or organization managing shall choose to issue an electronic health insurance card or a paper health insurance card based on the declaration form or the list of participants. In the event of changes to the information of relatives or changes to the benefits entitled, the health insurance participant must provide a scanned copy of the relevant documents and materials to be submitted along with the declaration form on the National Public Service Portal or through the application of the social security authority, or submitted directly at the one-stop division of the health security authority tasked with reception or sent via public postal services to the health security authority tasked with reception.

c) The National Public Service Portal or the application of the social security authority shall automatically issue a receipt for the application and schedule the return of the health insurance card issuance results for the health insurance participant or for the managing agency or organization. In the case where the application is directly at the one-stop division of the social security authority, the staff receiving the application at the one-stop division will directly check the application, issue a receipt of the application, and schedule the return of the health insurance card issuance results for the health insurance participant or for the managing agency or organization;

d) In the case where an electronic health insurance card is issued, within 05 working days from the receipt of a complete application according to the provisions specified in points a, b, and c of this clause, the social security authority shall send the electronic health insurance card issuance results to the digital social security application (VssID), personal email, linked to the level 2 e-ID account (VNeID). The health insurance participant shall use an electronic device with an installed and logged-in VNeID or VssID application connected to the internet to receive the electronic health insurance card.

In the case where a paper health insurance card is issued, within 05 working days from the receipt of a complete application as stipulated in points a, b, and c of this clause, the social security authority shall transfer the paper health insurance card to the health insurance participant or the managing organization to subsequently return it to the health insurance participant.

3. For children under 6 years of age, the issuance of health insurance cards shall be carried out in conjunction with the birth registration and permanent residence registration as stipulated in Decree No. 63/2024/ND-CP dated June 10, 2024 of the Government on the implementation of electronic interconnection for 02 groups of administrative procedures: birth registration, permanent residence registration, issuance of health insurance cards for children under 6 years old; death registration, deletion of permanent residence registration, settlement of burial expenses, death benefits.

4. The Military and Social Security Authority shall issue health insurance cards to the entities specified in clause 7, Article 5 of this Decree.

Article 12. Revocation, temporary confiscation or temporary invalidation of health insurance cards

1. Health insurance cards shall be revoked in cases prescribed in Clause 1, Article 20 of the Law on Health Insurance.

2. Cases of fraud in the issuance of health insurance cards include:

a) Fraudulent acts in terms of eligibility and the reimbursement rates in the issuance of health insurance cards;

b) Other fraudulent acts.

3. Health insurance cards are temporarily confiscated or temporarily invalidated in cases stipulated in Clause 2 of Article 20 of the Law on Health Insurance.

4. Upon detecting violations specified in clauses 1, 2, and 3 of this Article, health facilities shall notify social security authorities.

5. Social security authorities shall revoke, temporarily confiscate, or temporarily invalidate health insurance cards when they detect or receive notifications from health facilities of violations of the provisions specified in Clauses 1, 2, and 3 of this Article.

6. Social security authorities must notify health insurance participants of the revocation, temporary confiscation or temporary invalidation of health insurance cards.

7. The health insurance card that has been temporarily invalidated shall be reactivated and the health insurance card that has been temporarily confiscated shall be returned if the person lending their card to another person and the holder of someone else's health insurance card have fulfilled their obligations to pay fines and rectify the consequences (if any) in accordance with the administrative penalty decision for cases specified in Clause 3 of this Article.

Article 13. Time when a health insurance card is valid for use

1. For the entities specified in point dd, clause 2, Article 12 of the Law on Health Insurance: From the date of receiving unemployment benefits stated in the decision made by the competent state authority.

2. For the entities specified in point h, clause 3, Article 12 of the Law on Health Insurance:

a) In the case of a child born on or before September 30: from the date of birth until the end of September 30 of the year the child turns 72 months old;

b) In the case of a child born after September 30: from the date of birth until the end of the month the child turns 72 months old.

3. For the entities specified in point r, clause 3, Article 12 of the Law on Health Insurance: from the date of receiving social assistance stated in the decision of the People's Committee according to the delegated authority.

4. For entities specified in point o clause 3 and point a clause 4 Article 12 of the Law on Health Insurance whose health insurance premiums are fully subsidized by the state: from the day stated in the decision to approve the list of the competent state authority.

5. For the entities specified in point m, clause 3, Article 12 of the Law on Health Insurance: immediately after the body part is donated.

6. For the entities specified in point h, clause 4, Article 12 of the Law on Health Insurance: from the day stated in the decision to approve the list of the competent state authority.

7. For the entities specified in point b clause 4 Article 12 of the Law on Health Insurance who are students of general education institutions and pay annual health insurance premiums:

a) First-grade students: from the 1 ^st of October in the first year of primary education; from the last day of the month when the child turns 72 months of age regarding the cases specified in point b, clause 2 of this Article;

b) Twelfth grade students: from January 1 ^st to the end of September 30 ^th of that year. Encouraging 12 ^th-grade students to pay health insurance and receive the subsidies until the end of December 31 of their final academic year to ensure the continuity of health insurance benefits, without the obligation to return the state subsidies provided by the state in case of changes in eligibility.

8. For the entities specified in point b, clause 4, Article 12 of the Law on Health Insurance who are students of higher education institutions and vocational education institutions and pay annual health insurance premiums, including:

a) First-year students of a course: from the date of enrollment; in the case where the health insurance card of a 12 ^th-grade student is still valid after the enrollment date, health insurance premium shall be paid from the expiry date of the health insurance card;

b) Final-year students of a course: From the first day of January to the last day of the month in which the course ends. Encouraging final-year students of the course to pay health insurance and receive the subsidies until the end of December 31 of their final academic year to ensure the continuity of health insurance benefits, without the obligation to reimburse the state subsidies provided by the state in case of changes in entities.

9. For other entities, a health insurance card is valid from the date the participant starts pay for health insurance, except for the cases specified in point c, clause 3, Article 16 of the Law on Health Insurance.

10. The validity of each health insurance card prescribed in this Article shall be equivalent to the amount of health insurance premiums as per regulations, except for entities who are children under 6 years of age.

Chapter IV

HEALTH INSURANCE COVERAGE, HEALTH INSURANCE REIMBURSEMENT RATES OF HEALTH INSURANCE PARTICIPANTS

Article 14. Health insurance coverage in terms of patient transportation costs

1. A health insurance participant who falls under the categories specified in points a, b, c, d, dd, e, h, i, o, and r of Clause 3, Article 12 of the Law on Health Insurance, in cases of inpatient treatment or emergency care, must be transferred to a health facility for which transportation costs will be covered.

2. The health insurance fund shall cover the patient transportation costs for the referring health facility based on the patient transportation service charge. To be specific:

a) For state-run health facilities, the patient transportation costs shall be paid according to the patient transportation service charge approved or prescribed by competent authorities.

b) For private health facilities, patient transportation service charges of state-run health facilities, shall be the basis for payment of patient transportation costs similarly to reimbursement of technical service costs in health insurance-covered medical care for private health facilities stipulated in Article 47 of this Decree.

3. In cases where the transportation service charge is not available, the transportation costs that can be reimbursed by the health insurance fund shall be determined based on the following criteria:

a) Based on the actual distance between the two health facilities;

b) The reimbursement for fuel costs shall be calculated based on a standard of 0,2 liters of gasoline consumed per 01 km and the ratios or reimbursement rates stipulated in Article 22 of the Law on Health Insurance shall not be applied. The unit price of gasoline shall be in accordance with the common gasoline price set in the area of the health facility and at the time of referring the patient recorded on the patient referral form.

4. For a health facility providing patient transportation services in cases where the transportation service charges have not yet been approved or set by competent authorities, the health insurance fund will reimburse as follows:

a) Reimbursement for transportation costs of both the outbound and inbound trips for the referring health facility shall be calculated according to the unit price on the invoice for purchased gasoline or oil, depending on the actual type of gasoline or oil consumed by the vehicle used for patient transportation, but shall not exceed the reimbursement for fuel costs specified in point b, clause 3 of this Article.

b) In cases where the patient transportation means do not use fuel such as gasoline or oil, the reimbursement for fuel costs specified in point b, clause 3 of this Article shall apply;

c) In cases where more than one patient is transported on a single vehicle, the reimbursement shall be calculated according to the specified rate applicable for the transportation of one patient.

d) The health facility that refers a patient to another health facility is responsible for compiling a statement of all transportation costs and settling payments with the social security authority. The health workers of the health facility receiving the patient (hereinafter referred to as “receiving health facility”) shall add a countersign on the vehicle dispatch order from the transferring health facility.

5. For patients who arrange their own means of transportation, the health insurance fund shall reimburse as follows:

a) The transportation costs of the outbound trip shall be reimbursed in accordance with the invoice for transferring patients to the receiving health facility and not exceed the reimbursement specified in points a and b of clause 3 of this Article;

b) The referring health facility has the responsibility to document the patient's self-arranged transportation means on the referral form;

c) The receiving health facility shall reimburse the costs to the patient based on the transportation invoice provided by the patient in accordance with the provisions in point a of this clause, and shall consolidate the transportation costs for payment with the social security authority.

Article 15. Health insurance reimbursement rates for certain entities and cases

1. Participants in health insurance who fall under the categories specified in clauses 1, 2, 3, 4, 5, 6, and 7 of Article 5 of this Decree, when receiving medical care in accordance with the provisions of Articles 26 and 27 of the Law on Health Insurance, are entitled to have their health insurance-covered medical care costs covered by the health insurance fund within the scope of their health insurance coverage at the following reimbursement rates:

a) 100% of the medical care costs, for the entities specified in clauses 2 and 6 of Article 5 of this Decree;

b) 100% of the medical care costs, for the entities specified in clauses 1, 3, 4, 5 and 7 Article 5 of this Decree.

2. Health insurance participants covered by points a, b, c, d, and dd of Clause 3, Article 12 of the Law on Health Insurance, when requiring medical care at health insurance-covered medical care facilities not under the management of the Ministry of National Defense or the Ministry of Public Security, are entitled to have their medical care costs covered by the health insurance fund in accordance with the imbursement rate specified in Article 11 of Decree No. 70/2015/ND-CP dated September 1, 2015 issued by the Government providing detailed regulations and implementation guidance of certain Articles of the Law on Health Insurance for the People's Army, the People's Police, and those working in cryptography, which is amended and supplemented by Decree No. 74/2025/ND-CP dated March 31, 2025, by the Government.

Article 16. Participants to whom the co-payment rates mentioned in Point c Clause 2 Article 21 of the Law on Health Insurance

Participants to whom the co-payment rates mentioned in Point c Clause 2 Article 21 of the Law on Health Insurance include:

1. Persons who are revolutionary prior to January 1, 1945.

2. Persons who are revolutionists from January 1, 1945 to the commencement of the August Revolution in the year 1945.

3. Vietnamese heroic mothers.

4. War veterans, individuals benefiting from policies akin to those for war veterans, Category-B war veterans, disabled veterans with a reduction in labor capacity of 81% or more.

5. Wounded soldiers, individuals benefiting from policies similar to wounded soldiers, Category-B wounded soldiers, and sick soldiers during the treatment of injuries and the recurrence of illnesses.

6. Resistance fighters who have been exposed to chemical agents and experience a reduction in labor capacity of 81% or more.

7. Children aged under 6.

Article 17. Application of Health insurance reimbursement rates for certain cases

1. The medical cost of an occasion of service must be lower than 15% of the statutory pay rate in order for health insurance participants to receive 100% reimbursement of the medical care costs stipulated in point b, clause 1, Article 22 of the Law on Health Insurance.

2. The provisions in point b clause 1 Article 22 of the Law on Health Insurance and clause 1 of this Article shall apply to cases where health insurance participants visit health facilities in accordance with the provisions in clauses 1, 3, 4, and 5 of Article 22 of the Law on Health Insurance.

3. The provisions in points dd and e clause 1 Article 22 of the Law on Health Insurance shall apply to cases where health insurance participants visit health facilities in accordance with the provisions in clauses 3, 4 and 5 Article 22 of the Law on Health Insurance, except for the cases specified in clause 2 of this Article and the entities whose reimbursement rate is 100% of the medical care costs.

4. Participants in health insurance with different imbursement rates stipulated in Clause 1, Article 22 of the Law on Health Insurance shall apply according to the case with the highest imbursement rate. In cases where the imbursement rates specified in points a, b, c, and d clause 1 Article 22 of the Law on Health Insurance apply, the imbursement rates for the entities specified in points dd and e Clause 1, Article 22 of the Law on Health Insurance shall not apply.

Article 18. Application of imbursement rates for cases with health insurance participation period of 5 continuous years or more

1. Certain cases in which participants are considered to have continuously participated in health insurance in order to apply the reimbursement rate for the participants with health insurance participation period of 5 continuous years or more as stipulated in point d, clause 1, Article 22 of the Law on Health Insurance:

a) In the event of an interruption in health insurance participation within 90 days, it is still considered continuous participation in health insurance;

b) Individuals who are assigned by the competent authorities to go on business trips, study or work abroad or to go aboard as spouses or biological children and legally adopted children under 18 years of age to accompany their fathers or mothers on official duty at overseas Vietnamese agencies shall have their time spent abroad included in health insurance participation period;

c) Employees going abroad for work according to the Law on Vietnamese Guest Workers and those sent by regulatory agencies for work abroad shall have their health insurance participation period prior to their departure for labor abroad included in the time spent participating in health insurance, provided that they continue paying for health insurance within 30 days from the date of entry (upon repatriation);

d) Employees during the time of processing the application for unemployment benefits as stipulated by the Law on Employment, except for the duration from the date of termination of the labor contract or employment contract to the date the application for unemployment benefits is submitted, shall have their previous time spent participating in health insurance included in the time spent participating in health insurance;

dd) The entities specified in points a, b, and d of Clause 3, Article 12 of the Law on Health Insurance, when retiring, discharged from military service, changing professions, or resigning, shall have the time spent studying and working in the people's army, the people's police, and cryptographic organizations accounted for in the health insurance participation period. In cases where there is insufficient basis to determine the health insurance participation period, social security authorities shall rely on one of the documents issued by military units, police units, or cipher units that reflect the work record such as: Social insurance book, demobilization decision, resignation decision; background information: Professional servicemen and servicewomen, national defense workers and officials, public security personnel, and cryptography staff; a written confirmation of the working process issued by the unit at the regiment level or equivalent level and above to determine the health insurance participation period for the entities;

e) The entities specified in point dd of clause 3, Article 12 of the Law on Health Insurance, when ceasing to perform the obligation of regular militia service, shall have the duration of such service counted as the health insurance participation period.

2. The medical care costs for patients who have participated in health insurance for 05 consecutive years or more and whose copayments in a year exceed 06 months of the statutory pay rate as stipulated in point d, clause 1, Article 22 of the Law on Health Insurance are as follows:

a) The health insurance fund shall cover 100% of the medical care costs within the health insurance coverage of the health insurance participants from the moment the patient has participated in health insurance for 5 consecutive years or more and has a co-payment in the fiscal year greater than 6 months of the statutory pay rate until December 31 of that year; in cases where the health insurance participant starts his/her medical care period before January 1 and finishes the medical care period or is discharged from hospital from January 1 of the following year, the treatment costs shall be determined on a yearly basis to calculate the co-payment amount.

b) The social security authority shall compile the information on the cumulative co-payment during the fiscal year of the patients, the time at which the patients have participated in health insurance for at least 05 consecutive years, and communicate this information via the data reception portal of the Vietnam Social Security. The health facility, based on the cumulative co-payment and the time at which the patient has participated in health insurance for at least 5 consecutive years, shall determine the time at which the patient qualifies for the exemption from co-payment during their occasion of service;

c) In the event that the statutory pay rate changes during the year, the method for determining the remaining amount to be co-paid from the time the statutory pay rate changes until the end of December of that year is as follows:

For cases where the copayment from January 1 ^st until the day before the change in the statutory pay rate in the year is equal to the statutory pay rate or exceeds 6 months’ statutory pay rate, the entitlement shall be granted in accordance with the regulations, and this formula shall not apply.

Article 19. The implementation roadmap and the reimbursement rates when receiving outpatient care at secondary health facilities as prescribed in points e and h of clause 4, Article 22 of the Law on Health Insurance

1. From January 1, 2025, when receiving outpatient care at a secondary health facility that scores below 50 points or at a health facility that is temporarily classified as a secondary health facility, health insurance participants will be reimbursed in full by the health insurance fund, except for secondary health facilities that, prior to January 1, 2025, have been classified by competent authorities as provincial or central level health facilities.

2. From July 1, 2026, when receiving outpatient care at secondary health facilities that achieve a score between 50 and under 70 points, health insurance participants will be eligible for 50% of the reimbursement rate from the health insurance fund.

3. From July 1, 2026, when receiving outpatient care at secondary health facilities that have been classified by competent authorities as provincial-level or central level health facilities or equivalent facilities before January 01, 2025, health insurance participants will be eligible for 50% of the reimbursement rate from the health insurance fund.

4. From July 1, 2026, when receiving outpatient care at tertiary health facilities that have been classified by competent authorities as provincial-level health facilities before January 01, 2025 as prescribed in point h clause 4 Article 22 of the Law on Health Insurance, health insurance participants will eligible for 50% of the reimbursement rate from the health insurance fund.

Article 20. Reimbursement rates for cases where health insurance participants receive on-demand healthcare services

1. Individuals holding health insurance cards who receive on-demand healthcare services shall be entitled to reimbursement for the medical care costs by the health insurance fund, in accordance with the health insurance coverage and the reimbursement rates provided by health insurance laws. The difference between the costs of on-demand healthcare services and the costs covered by the health insurance fund is to be paid by the patient to the health facility.

2. Health facilities are responsible for ensuring adequate human resources, specialized conditions, transparently disclosing the costs that patients must cover outside the health insurance coverage and the reimbursement rates, as well as any additional costs, and must inform the patients in advance.

Article 21. Regulations on the effective date of health insurance reimbursement rates in cases of multiple reimbursement rates or changes in reimbursement rates

1. In the case where a participant in health insurance is eligible for multiple reimbursement rates stipulated in Article 22 of the Law on Health Insurance, they shall receive the highest applicable reimbursement rate.

2. In the case of changing the health insurance reimbursement rate, the new health insurance reimbursement rate will be applied from the effective date of the new health insurance card. Patients with health insurance cards who are undergoing inpatient treatment and experience changes in their health insurance reimbursement rates are responsible for providing information regarding the cards related to the changes in the reimbursement rates. The health facilities are responsible for verifying the entitlements and reimbursement rates of health insurance participants before the conclusion of their occasions of service or hospital discharge.

Chapter V

PROVIDER CONTRACT

Article 22. Conditions for conclusion of provider contracts

1. Ensure the operating conditions of health facilities in accordance with the provisions of Article 49 of the Law on Medical Examination and Treatment, suitable for the scope of health insurance-covered medical care services.

2. Ensure compliance with the standards for connectivity and interoperability of health insurance-covered medical care data with the system of health insurance assessment and information of the social security authorities, as regulated by the Minister of Health, and authenticate the payment data on payment for medical care costs in accordance with legal regulations.

Article 23. Provider contracts

1. The provider contract is signed between a health facility that meets the conditions specified in Article 22 of this Decree and the social security authority authorized to undertake the task of signing the contract.

a) Each operating license is used to sign one provider contract, except in cases specified in points b and dd of this clause.

b) In the case where a health facility has branches in the same province or central-affiliated city, it may sign one provider contract with the social security authority, or a separate provider contract between each branch and the social security authority;

c) In the case where a health facility has branches in a different province or central-affiliated city, each branch may sign one provider contract with the social security authority in the province/city where it is located;

d) In case a health facility has an affiliated branch that meets the conditions specified in Article 22 of this Decree but does not have the same professional classification, it shall sign separate provider contract;

dd) In the case of a health facility under the management of the Ministry of National Defense or the Ministry of Public Security, such facility may sign one provider contract with the military or police social security authority and one contract with the social security authority affiliated to the Vietnam Social Security.

2. The provider contract shall be made using Form No. 5 of the Appendix enclosed herewith and shall contain the basic contents prescribed in Article 25 of this Decree. The Appendix to the contract as stipulated in Clause 2, Article 24 of this Decree and the written notifications as required in Clause 3, Article 24 of this Decree are integral components of the contract and shall be effective during the validity period of the contract.

3. In cases of changes as stipulated in Clause 2, Article 24 of this Decree, the health facility and the social security authority must sign an addendum to the contract in accordance with the provisions of Article 29 of this Decree.

4. The provider contract shall be effective from the date on which the contract is signed or as the specific provisions in the contract.

5. A provider contract is a contract without a fixed term or with a fixed term as agreed upon by both parties, except in cases of termination of the contract as stipulated in points b, c, d, and dd of Clause 1, Article 32 of this Decree. Annually, at the end of the fiscal year, the social security authority and the health insurance-covered health facility shall mutually agree on the contents and the medical care costs proposed for payment, advanced, assessed, paid, unpaid, settled, denied for payment, reclaimed within the year, and the methods and timeframes for resolving each undisputed item, as well as the obligations to be fulfilled by each party. This serves as the basis for the health facility to exercise its financial rights and obligations, to settle accounts, and to pay taxes (if applicable) on time, and for the social security authority to conduct a summary report and settlement.

6. When terminating a contract, the parties must undertake the contract finalization procedures using Form No. 6 in the Appendix enclosed herewith and the provisions set forth in Article 33 of this Decree.

7. A health facility shall only provide health insurance-covered medical care services and pay health insurance-covered medical care costs from the effective date of the provider contract. The parties to the contract must ensure the conditions of the contract are upheld throughout the duration of its implementation.

8. The signer of the provider contract of a health facility is the head of the facility as specified in Clause 7, Article 2 of Decree 96/2023/ND-CP dated December 30, 2023, of the Government, elaborating several provisions of the Law on Medical care; the person registered as the holder of the household business license of the private health facility, the person assigned as the head of the health facility in the cooperative charter, or the deputy designated or authorized by the aforementioned individuals.

9. For units and schools that are not state agencies or public service providers, the health facilities of these units and schools shall apply the regulations on provider contracts applicable to private health facilities.

Article 24. Circumstances for signing an addendum to contracts and notifying changes in the implementation of provider contracts

1. During the execution of a contract, if there are any issues arising or changes related to the execution of the contract, the parties shall carry out the procedures for signing an addendum to the contract in accordance with the provisions of Clause 2 of this Article; notify as stipulated in Clause 3 of this Article; and terminate the contract in accordance with the provisions of Article 32 of this Decree.

2. In the event of changes to the name, seal, accounts, account holder of the health facility or social security authority, changes in professional classification, changes in the number of hospital beds necessitating the adjustment of the operational license, or changes in the payment method, an addendum to the contract shall be signed.

3. In other cases where contents related to the execution of the contract arise or change but the changes do not fall under the provisions of Clause 2 of this Article and Article 32 of this Decree, the parties shall not be required to sign a new contract or addendum to the contract. The health facility and the social security authority that have signed a contract shall carry out the notification procedure as a basis for implementation as follows:

a) The health facility shall send a document containing information and materials related to the changes to the social security authority where the contract is signed. The document signed and issued by the health facility is the original, while the document issued by the competent authority is a photocopy with the seal of the health facility for confirmation;

b) In the event that the social security authority provides feedback on the changes or issues arising of the health facility, within 05 working days from the receipt of the written notification from the health facility, the social security authority is responsible for sending a written response to the health facility, clearly stating the contents and reasons. In the event that the social security authority does not provide any feedback within 05 working days from the date of receipt of the written notification, it shall be deemed as approval.

c) Within 15 days from the receipt of the written response containing the feedback of the social security authority, the health facility is responsible for sending a written response to the feedback of the social security authority.

4. Pending the signing of the addendum to a contract, the health insurance fund shall continue to cover the health insurance-covered medical care costs for the health facility, ensuring continuity.

Article 25. Contents of provider contracts

1. Fundamental contents of a provider contract in accordance with the provisions of clause 2 Article 25 of the Law on Health Insurance shall be made using Form No. 5 of the Appendix enclosed herewith. In the case where a health facility has established multiple affiliated branches that are granted operating licenses at different locations and they sign a common contract, the content for each affiliated branch must be clearly specified.

2. The content regarding the served entities and the requirements about the scope of professional operation of the health facility must be consistent with the scope of practice approved by the competent authority. The expected number of cards and the structure of the participants in group health insurance in the health insurance-covered primary care provider must comply with the regulations of the Minister of Health.

3. Depending on the conditions of the health facility, the social security authority and the health facility may supplement other contents in the contract, which must be agreed upon and consented to by both parties, and must not contradict the provisions of the law. In the event that an agreement or consensus is not reached between both parties regarding the supplementary content, it shall not be included in the contract.

4. The method of payment for medical care costs shall comply with the provisions of Chapter VII of this Decree.

5. The provisions regarding the payment and settlement of health insurance-covered medical care costs in the contract shall be mutually agreed upon by both parties in accordance with the regulations set forth in this Decree and the laws on health insurance.

6. The term of the provider contract shall comply with the provisions of Article 23 of this Decree.

7. The method of resolving contractual disputes shall be determined by mutual agreement between the two parties. In the event that the parties choose to initiate litigation in court to resolve contractual disputes, they shall comply with the provisions of civil law. In the event of any issues arising concerning policies, laws, regulations, or professional guidelines, the parties shall report and submit recommendations to the competent regulatory authority for resolution.

8. Regulations regarding the notification and feedback between the parties in the event of changes or issues arising related to the execution of the contract; mechanisms for receiving and responding to information related to the transfer, sending of appraisal data and payment of health insurance-covered medical care costs.

Article 26. Applications for signing provider contracts

1. An application for signing a provider contract signing includes:

a) The written request for the signing of a provider contract by the health facility made using Form No. 7 of the Appendix enclosed herewith;

b) A photocopy of the medical care license issued by the competent regulatory authority to the health facility, bearing the official seal of the facility to validate it;

c) A photocopy of the decision on professional classification or temporary professional classification of the health facility from the competent authority; in the cases specified in points dd and h of Clause 4, Article 22 of the Law on Health Insurance and Clauses 3 and 4 of Article 19 of this Decree, there must also be a photocopy of the document from the competent authority confirming that the health facility has been classified in terms of specialized technical services prior to January 1, 2025. These documents must bear the official seal of the health facility for validation;

d) A photocopy with the official seal of the health facility to confirm that the decision to approve the list of medical technical services has been approved by the competent authority;

dd) List of medications and medical devices used at the health facility;

e) The list of personnel and the total number of hospital beds of the health facility by each professional department, division or unit approved by the competent authority;

g) A photocopy with the official seal of the health facility to confirm that the decision to approve service charges included in the list of medical care services covered by the health insurance fund has been approved by the competent authority. In the case specified in Article 47 of this Decree, the health facility shall submit a written proposal of the health insurance-covered medical care service charges to determine the payment level at the facility.

h) A list of software and hardware devices that ensure the interconnection for the electronic transfer of data in health insurance payments according to Form No. 8 of the Appendix enclosed herewith;

i) For the documents specified in points b, c, d, and g of this clause, the health facility is not required to submit a photocopy in cases where the competent authority has sent the written proposal to the social security authority upon issuance or when the written proposal can be retrieved from the online system of the competent authority. However, the health facility must reference the address of the website that can be searched in the written request for signing the provider contract specified in point a of this clause.

2. In the case of signing a follow-up contract when the previous contract has expired or both parties agree to early terminate the contract, provided that there are no changes to the documents, the health facility is not required to resubmit and may use the application submitted when signing the previous contract. In the event that the documents included in the application specified in Clause 1 of this Article of the health facility undergo changes, the health facility is only required to submit the documents that prove the changes.

3. Number of applications: 01 application.

4. The application is submitted electronically through the National Public Service Portal or via the application of the social security authority. During the period when the online public service system is not yet completed, individuals in administrative divisions in areas with difficult or particularly difficult socio-economic conditions may submit their applications directly at the one-stop division of the social security authority tasked with receipt of applications, or send them via public postal services to the social security authority tasked with receipt of applications.

Article 27. Applications for signing the addenda to contracts

1. An application for signing a addendum to a contract includes:

a) The written request for the signing of the addendum to the provider contract by the health facility or the social security authority made using Form No. 7 of the Appendix enclosed herewith;

b) A photocopy of the documentary evidence showing the change in relation to the case stipulated in Clause 2, Article 24 of this Decree, bearing the official seal of the health facility or the social security authority for confirmation.

2. Number of applications: 01 application.

3. The application is submitted electronically through the National Public Service Portal or via the application of the social security authority. During the period when the online public service system is not yet completed, individuals in administrative divisions in areas with difficult or particularly difficult socio-economic conditions may submit their applications directly at the one-stop division of the social security authority tasked with receipt of applications, or send them via public postal services to the social security authority tasked with receipt of applications.

Article 28. Procedures for signing provider contracts

1. A health facility shall submit an application in accordance with the provisions of Article 26 of this Decree to the social security authority tasked with signing of the contract.

2. In the absence of requests for amendments or additions to the application, within 10 days from the receipt of complete and valid application and fulfillment of conditions for signing the contract (in the case of submission of physical application, based on the date recorded on the received date stamp), the social security authority must complete the contract signing.

3. In the event of a request for amendments or additions to an application, the following procedures shall be followed:

a) Within 05 working days from the receipt of the application (in the case of submitting a physical application, based on the date recorded on the received date stamp), the social security authority is responsible for responding in writing, specifying the content that needs to be amended or supplemented, to the health facility.

b) Within 30 days from the receipt of the written request for amendments or additions to the application (in the case of submitting a physical application, based on the date recorded on the received date stamp), the health facility is responsible for amending or supplementing the application and sending it to the social security authority. In the event that the health facility does not supplement and submit the application after 30 days, it is necessary to repeat the procedures outlined in clauses 1 and 2 of this Article;

c) Within 10 days from the receipt of the amended application (in the case of submitting a physical application, based on the date recorded on the received date stamp), the social security authority shall sign a contract if conditions are met, or issue a written notification of refusal to sign the contract if the conditions are not met, clearly stating the reasons and the legal basis for determining that the conditions for signing the contract have not been met.

4. The assessment for signing a provider contract shall be carried out based on the application submitted by the health facility in accordance with the provisions of Article 26 of this Decree. The health facility is entirely responsible before the law for the accuracy of its application and must ensure compliance with the operational conditions for medical care as prescribed by law.

5. In the event of signing a follow-up contract after the original contract has expired or when both parties mutually agree to prematurely terminate the contract, the parties shall proceed with the procedures as stipulated below:

a) The health facility shall submit an application in accordance with the provisions of clause 2 Article 26 of this Decree to the social security authority tasked with signing of the contract.

b) In the absence of requests for amendments or additions to the application, within 03 working days from the receipt of complete and valid application and fulfillment of conditions for signing the contract (in the case of submission of physical application, based on the date recorded on the received date stamp), the social security authority must complete the contract signing.

c) In case where there is a request for amendments or additions to the application, within 02 working days from the receipt of the application (in the case of submitting a physical application, based on the date recorded on the received date stamp), the social security authority is responsible for responding in writing, specifying the content that needs to be amended or supplemented, to the health facility;

d) Within 10 days from the receipt of the written request for amendments or additions to the application (in the case of submitting a physical application, based on the date recorded on the received date stamp), the health facility is responsible for amending or supplementing the application and sending it to the social security authority. In the event that the health facility does not supplement and submit the application after 10 days, it is necessary to repeat the procedures outlined in this Article;

dd) Within 03 working days from the receipt of the amended application (in the case of submitting a physical application, based on the date recorded on the received date stamp), the social security authority shall sign a contract if conditions are met, or issue a written notification of refusal to sign the contract if the conditions are not met, clearly stating the reasons and the legal basis for determining that the conditions for signing the contract have not been met.

e) In cases where the health facility and the social security authority agree to continue renewing the contract upon the expiration of the existing provider contract, the renewal of the contract must ensure that the effective date of the follow-up contract aligns with the duration of the previous contract.

Article 29. Procedures for signing addenda to provider contracts

1. Within 03 working days from the date on which the competent authority issue a document on the changes in the case specified in Clause 2, Article 24 of this Decree, the social security authority or the health facility shall send the application for signing the addendum to the contract to the other party.

2. Within 05 working days from the receipt of the application, the health facility and the social security authority shall complete the signing of the addendum to the contract.

Article 30. Signing provider contracts at communal health stations, ward health stations, special-zone health stations, maternity homes, regional polyclinics, and health facilities of agencies, organizations, and schools

1. For communal health stations, ward health stations, special-zone health stations, maternity homes, and regional polyclinics, provider contracts shall be signed according to one of the following two forms:

a) The provincial People's Committee shall decide one representative unit to sign a contract with the social security authority for the communal health stations, ward health stations, special-zone health stations, maternity homes, and regional general clinics under its management.

b) The commune, ward, and special zone health stations, maternity homes, and regional general clinics directly shall sign contracts with the social security authority.

2. For the health facilities of agencies, units, and schools (excluding those agencies, units, and schools that receive funding for medical care in accordance with the provisions of Article 63 of this Decree), the social security authority shall directly sign a provider contract with the agencies, units, and schools.

3. The contracting unit specified in clauses 1 and 2 of this Article is responsible for ensuring the operational conditions of the health facility in accordance with the signed contract.

Article 31. Suspension of provider contracts

1. A provider contract shall be suspended in whole or in part in the event that the health facility is entirely or partially suspended from operation by the decision of the competent authority.

2. When deciding to entirely or partially suspend operations of a health facility, the competent authority is responsible for sending a notification to the social security authority where the contract is signed. The suspension of the provider contract shall start from the effective date of the decision to entirely or partially suspend operations of the health facility. When making the decision to allow the health facility to resume operations, the competent authority is responsible for sending a notification to the social security authority where the contract is signed.

3. In the event that a health facility's operations are suspended and subsequently permitted to resume by a competent authority, the facility must provide a written notification to the social security authority of the continuation of the contract and documentary evidence in case of any changes compared to the application for signing provider contract prior to the suspension.

4. When suspending the contract, both parties must agree on a plan to ensure the rights and interests of the patients during the suspension period. When continuing to execute the contract, the health facility is responsible for making sure that the conditions for operation are in accordance with the signed provider contract.

Article 32. Circumstances for termination of provider contracts and procedures for termination of provider contracts

1. Circumstances for termination of a provider contract include:

a) Upon expiration of the contract;

b) Both parties agree to early terminate the contract;

c) The health facility shuts down, undergoes dissolution, or goes bankrupt;

d) The health facility has its operating license revoked;

dd) After the expiration of the 03-month suspension period, if the health facility has not rectified the violations, it shall not be allowed to resume operations.

2. Upon the expiration of the contract as stipulated in points a and b of Clause 1 of this Article, the parties shall carry out the contract finalization procedures in accordance with the provisions of Article 33 of this Decree.

3. In the case of termination of the contract as stipulated in points c and d of Clause 1 of this Article, within 03 working days from the date of shutdown as decided by the competent state authority, the health facility is responsible for notifying the social security authority where the contract is signed of the termination of the contract. The parties shall carry out the contract finalization procedure in accordance with the provisions of Article 33 of this Decree. The termination of the contract shall take effect from the effective date of the decision to shut down the health facility or to revoke the operating license of the health facility.

4. In the event that the deadline specified in point dd of Clause 1 of this Article has passed and the health facility has not been authorized by the competent authority in accordance with the law on health examination and treatment to resume operations, the social security authority where the contract is signed and the health facility shall terminate the contract and finalize the contract in accordance with Article 33 of this Decree.

Article 33. Finalization of provider contracts

1. The provider contract signed by a social security authority and a health facility shall be finalized after termination of the contract as prescribed in Article 32 of this Decree. The provider contract finalization template shall be made using Form No. 6 of the Appendix enclosed herewith.

2. The finalization of a contract shall comply with the provisions of civil law.

3. Both parties shall compare, determine, and agree upon the items and costs of medical care proposed for payment, advanced, assessed, paid, unpaid, settled, refusals of payment, refused to pay, recovered within the year, and the method and timeframe for resolving each content that has not been agreed upon, as well as the obligations to be fulfilled by each party; and any amounts to be reclaimed or refunded (if applicable) as the basis for terminating the contract. Upon agreement and confirmation, the social security authority shall execute the payment or recovery of related amounts in accordance with regulations.

4. The rights and obligations of social security authorities:

a) Verify and confirm the outstanding debts and the reconciliation documents of the health facility; request the reimbursement of any improper payments (if any); refuse to finalize the contract if the health facility has not fulfilled its financial obligations or has not provided sufficient documents for finalization purposes;

b) Take responsibility for settling any outstanding expenses in a timely manner; do not require to hand over original medical records, unless otherwise provided by law.

5. Rights and obligations of health facilities:

a) Request the social security authority to fully settle all costs that have been finalized; retain medical records in accordance with regulations and only hand over documents for finalization purposes; may propose to continue renewing the contract if needed and if they meet the stipulated conditions.

b) Responsible for completing financial settlements and reimbursing any amounts payable (if applicable); providing documentation to facilitate reconciliation and inspection while ensuring compliance with regulations on medical record retention, and being legally accountable for the records and documents for which payments have been made for the social security authority; ensuring the transfer of patients to other health facilities without impacting the rights of health insurance participants.

Article 34. Rights and responsibilities of social security authorities in contract execution

1. Rights of social security authorities:

a) The rights provided for in Article 40 of the Law on Health Insurance;

b) Requesting the health facilities to transfer the verified electronic data for the purpose of processing the health insurance-covered medical care costs in accordance with the regulations of the Minister of Health;

c) Requiring a health facility to explain in cases where the social security authority reports that the health insurance-covered medical care costs have exceeded the average increase of health facilities with the same level of technical expertise, of the same type of general or specialized health facilities in the year within the province, central-affiliated city, or nationwide, or the average increase of that facility in the same period of the previous year.

d) Refusing to pay for health insurance-covered medical care costs that do not comply with laws on health insurance and medical care.

2. Responsibilities of the social insurance authorities

a) Comply with the provisions of Article 41 of the Law on Health Insurance;

b) Provide health facilities with information about the medical history of health insurance participants;

c) Ensure the confidentiality of the information collected during the process of conducting assessments and processing health insurance-covered medical care costs, as well as the exploitation and use of medical records in accordance with the provisions of the law;

d) Coordinate with health facilities in verifying and clarifying information of health insurance participants upon request, and addressing difficulties and obstacles in receiving and reviewing health insurance-covered medical care procedures; consider the revocation, temporary confiscation, or temporary invalidation of health insurance cards and handle according to authority in cases of violations upon receipt of reported violation information; provide guidance and technical support in transferring electronic data to facilitate health insurance-covered medical care costs for health facilities.

dd) Maintain timely receipt and feedback regarding the acceptance of payment request data, return documents with errors specifically detailing the mistakes, the parts of the payment request that are returned due to errors, the results of the cost assessment, and any incidents or issues related to the data reception for health facilities as prescribed;

e) Provide advance payment, settlement, and finalization of health insurance-covered medical care costs on time and in the correct amounts, with the advance ratio in accordance with the provisions of the law on health insurance;

g) Reach an agreement on the number of applications sent for assessment, the amount of advance payments for health insurance-covered medical care costs for the next period when incidents or difficulties arise in receiving the data;

h) Inspect the implementation of the contract and verify the maintenance of conditions by the health facility after the contract has been signed.

3. Performing other rights and responsibilities as prescribed by the law on health insurance and medical care.

4. To be accountable to the state health management agency in cases where there are suggestions or reports of the social security authority violating the provider contract, including payment issues, refusal of payment, and recovery of medical care costs that do not comply with legal regulations.

Article 35. Rights and responsibilities of health facilities in executing contracts

1. Rights of health facilities

a) The rights stipulated in Article 42 of the Law on Health Insurance and the provisions of the law regarding examination and treatment.

b) Timely information shall be provided when the health insurance assessment information system identifies an increase in medical care costs that is significantly higher than the average cost at health facilities of the same professional classification, of the same type of general or specialized health facilities within the province, central-affiliated city, or nationwide, or the average increase of that facility in the same period of the previous year, in order to promptly review, inspect, verify, and implement appropriate adjustment measures;

c) It is proposed that the social security authority clarify the reasons for the delay in the payment and settlement of health insurance-covered medical care costs.

d) The social security authority shall promptly notify about any incidents in the data reception system, errors in the records, and the health insurance-covered medical care costs when submitting a payment request;

dd) It is recommended that the state management agencies in health and finance provide guidance and resolve any issues arising during the implementation of the contract;

e) The competent authority shall solicit opinions regarding the procedures and processes of medical care evaluation, as well as the regulations and policies concerning health insurance related to the rights and obligations of health insurance-covered medical care facilities.

2. Responsibilities of health facilities

a) Comply with the provisions in Article 43 of the Law on Health Insurance and the responsibilities as prescribed by law on examination and treatment.

b) Review and promptly issue the procedures and professional guidelines for health insurance-covered medical care; comply with legal regulations concerning medical care, the professional guidelines of the Ministry of Health, and relevant legal provisions regarding procurement and bidding to ensure the supply of quality, effective, and economical pharmaceuticals, chemicals, medical equipment, and technical medical services.

c) Submit electronic data regarding the health insurance-covered medical care costs after the patient's medical care session is completed, sign the summary table of medical care costs for health insurance participants monthly or quarterly as prescribed by the Minister of Health; verify the electronic data in accordance with legal regulations; and take legal responsibility for the accuracy of the summary table of medical care costs requiring payment with the health insurance-covered medical care costs of the patient;

d) Establish a technology infrastructure system, upgrade and complete the hospital management software system to comply with the legal regulations regarding input data standards, output data standards, electronic data extraction, digital transformation, and electronic transactions in the healthcare sector;

dd) Comply with regulations regarding the payment of health insurance-covered medical care costs; proactively review and inspect the rising health insurance-covered medical care costs of at the facility in accordance with recommendations and warnings from social security authorities; identify the subjective and objective causes, develop and implement solutions to address subjective causes and inadequacies, and submit them to the social security authority where the contract is signed.

e) Publicize the results of the professional classification approved by the competent authority along with the scores on the facility's website and at the patient reception area. The competent authority responsible for classifying technical expertise is required to publicly disclose the list of health facilities along with their scoring on the agency's web portal and on the information system for managing medical care activities;

g) In the case of providing medical care on holidays and weekends, the health facility must arrange sufficient specialized personnel, administrative departments, and financial accounting to meet the requirements of medical care, timely address the rights of patients, and comply with the scope of medical care during holidays and weekends.

h) Comply with regulations on the management and use of drugs and medical equipment to ensure quality and safety in the provision of health insurance-covered medical care services;

i) Ensure comprehensive designation and guarantee the scope of payment of the health insurance fund for participants based on professional requirements and medical conditions; it is prohibited to charge additional fees to patients with health insurance and to reimburse the social insurance authority for costs already included in the medical care service charges as stipulated or approved by competent authorities for health facilities.

3. To be accountable to the state health management agency in the event of recommendations or reports regarding health facilities that violate provider contracts.

4. Perform other rights and responsibilities as stipulated by the law on health insurance and medical care.

Article 36. Inspection of the execution of provider contracts

1. The inspection cases include:

a) Conduct regular inspections according to the annual plan;

b) Conduct unexpected inspections when violations of the law are detected or there are signs of violations related to the implementation of provider contracts.

2. Principles of inspection:

a) The inspection must be based on the inspection plan that has been approved by the competent authority;

b) The regular inspection ensures that the health facility is not subjected to more than one inspection regarding the same content within one year, including inspections by authorized agencies such as inspection, auditing, except in cases where violations of the law or signs of violations are detected.

c) The content of the inspection is based on the articles, clauses, contents, and responsibilities outlined in the signed provider contract. Do not review contents outside the scope of the signed provider contract and contents that do not fall under the functions and duties of the social security authority.

d) The inspection plan must be sent to the entity subject to inspection immediately after approval. The inspection time must be communicated to the entity subject to inspection at least 07 days prior to the inspection; for unscheduled inspections, a written notification must be provided to the entity at least 01 day in advance.

dd) The inspection conclusion must be sent to the inspected entity. Within 03 months from the date of receiving the inspection conclusion, the inspected entity must submit a report on the implementation of the inspection conclusion to the inspection authority.

3. The Minister of Finance shall regulate the authority to inspect the execution of the provider contracts.

Chapter VI

PROCEDURES FOR HEALTH INSURANCE-COVERED MEDICAL CARE SERVICE PROVISION

Article 37. Procedures for health insurance-covered medical care service provision prescribed in clause 1 Article 28 of the Law on Health Insurance

1. Health insurance participant when receiving medical care must present information regarding their health insurance card and documents proving their identity in one of the following formats:

a) Identity card or citizen identity card or level 2 electronic identification account (VNeID) in which information about the health insurance card has been integrated;

b) Electronic or physical health insurance card. For any of the health insurance participants stipulated in points a, b, c, and d of Clause 3, Article 12 of the Law on Health Insurance, who does not have information about their health insurance card available in the information technology system, a physical copy of the health insurance card must be presented. In cases where the health insurance card does not have a photo or health insurance number, the participant must additionally present one of the following documents to prove their identity: identity card, citizen identity card, identity certificate, passport, linked to level 2 electronic identification account (VNeID) or VssID application or other documents proving identity issued by the competent authorities or a written confirmation issued by the communal police.

2. For children under 6 years of age, it is necessary to present a physical or electronic health insurance card, or the health insurance number; in cases where the health insurance card has not been issued, the original or photocopy of the birth certificate must be presented. For newborns, the father, mother, or relatives of the child shall countersign the medical record, or a representative of the health facility shall confirm on the medical record in the case where the child has no father, mother, or relatives.

3. When visiting a health facility to receive medical care, a health insurance participant who is expecting a new health insurance card which is reissued or replaces the preexisting one must present the receipt of application and return the results of issuance, reissuance and replacement of health insurance card, information on the health insurance card issued by the social security authority or any entity or individual authorized by the social security authority to receive applications for reissuance and replacement of health insurance cards and any document proving personal identity of that participant according to the provisions of point b clause 1 of this Article.

4. The person who has donated a part of the human body must present information regarding the health insurance card in accordance with the provisions of clause 1 or clause 3 of this Article. In the case of not having a health insurance card, one must present the hospital discharge note issued by the health facility where the body part was harvested, and one of the identity documents of the person; these can include a national identity card, citizen identity card, identity certificate, passport, linked to the level 2 electronic identification account (VNeID), or the VssID application, or other identity documents issued by competent authorities or organizations. In cases where there is no health insurance card but immediate treatment is necessary after donation, the health facility and the patient or the patient's relatives shall confirm this in the medical record.

5. In cases of emergency, the health insurance participants must present the documents as prescribed in clause 1, clause 2, or clause 3 of this Article before the conclusion of the treatment period.

Article 38. Procedures for health insurance-covered medical care service provision in certain cases

1. In the case where a patient possesses a health insurance card and presents the card late during the medical care process, the health insurance fund will reimburse the costs of medical care within the scope of benefits and reimbursement rates from the time the health insurance card is presented, except in cases of emergency. The costs of medical care during the period when the patient has not presented their health insurance card will be reimbursed directly by the health insurance fund in accordance with the provisions set forth in Articles 55, 56, and 57 of this Decree.

2. For a patient who possesses an electronic health insurance card, when he/she requires health insurance-covered medical care but is unable to present the electronic health insurance card due to issues such as a failure to connect to the level 2 electronic identification account (VNeID), malfunction of the VssID application, or Internet connection errors, the following procedures shall be applied:

a) The patient provides their health insurance card number to the health facility for the purpose of retrieving information on the Data reception portal of the Vietnam Social Security. In the event that it is unable to retrieve information from the Data reception portal of the Vietnam Social Security, the health facility shall record the health insurance card number and accept the patient for medical care. The health facility shall cooperate with the social security authority in verifying the information on the health insurance card of the patient in order to determine the insurance coverage, benefits, and entitlement regime of health insurance.

b) In cases where, at the time the patient completes their occasion of service and is discharged from hospital but the electronic health insurance card management data system still encounters errors preventing information extraction and the social security authority has not yet verified and clarified the matter, the health facility is responsible for sending the complete medical record, contact information of the patient along with a screenshot of the query to the social security authority for further verification once the system is restored and for the appraisal and payment of medical care costs as prescribed. The patient is responsible for providing information about the participant in health insurance and the health insurance card to the health facility, and ensuring the accuracy of the information provided.

3. Health facilities and social security authorities shall not impose any additional procedures for health insurance-covered medical care service provision beyond those stipulated in this Article. In cases where health facilities and social security authorities need to photocopy health insurance cards and related documents concerning the medical care of patients for the purpose of management, they must do so independently after obtaining consents from the patients or their legal guardians. They are not allowed to request the patients to make photocopies or to cover the associated costs.

Chapter VII

METHODS OF PAYMENT OF HEALTH INSURANCE-COVERED MEDICAL CARE COSTS

Article 39. Method of service charge-based payment

1. The service charge-based payment is a payment method that relies on the medical care service charges and the costs included in the medical care service charges in accordance with the provisions of the law on medical care, which have not yet been included in the prices used to determine the reimbursement rates for medical care costs by the health insurance fund.

2. The reimbursement rates for medical care costs paid by the health insurance fund shall be determined as follows:

a) For state-run health facilities, the health insurance-covered medical care costs paid by the health insurance fund shall be equal to the medical care service charges included in the lists approved or regulated by the competent authorities.

b) For private health facilities, the health insurance fund shall reimburse the health insurance-covered medical care costs based on the medical care service charges included in the lists approved by the competent authorities in accordance with the law on medical care, or approved for state-run health facilities in their areas according to the principles stipulated in points a, b, c, and d of Clause 2, Article 47 of this Decree. The difference in the medical care service charges between private health facilities and the medical care service charges covered by the health insurance fund to be paid by the patients themselves.

3. For the medical care costs within the insurance coverage and reimbursement rates of health insurance participants included in the medical care service charges according to the roadmap and regulations of law on medical care which are not included in the service charges, the health insurance fund shall provide reimbursements based on the actual quantity used, the purchase price as stipulated by the law on bidding, or according to the reimbursement rates for medical care costs by the health insurance fund for private health facilities; costs of blood and blood products shall be reimbursed according to the regulations of the Minister of Health.

Article 40. Method of fixed rate-based reimbursement

1. The fixed rate-based reimbursement shall be applied to health insurance-covered outpatient care.

2. The fixed rate-based reimbursements shall include outpatient care costs within the health insurance coverage and the reimbursement rates of the holders of health insurance cards.

3. The Vietnam Social Security shall determine the fixed allocation fund for the year based on the total actual health insurance-covered outpatient care costs and the projected expenses for health insurance-covered medical care for the year, in accordance with the provisions of Clause 6 of this Article, in order to notify health facilities about health insurance.

4. In the case of allocated funding is in surplus within the year, health facilities may retain part of the surplus and record it as revenue from public service provision; the remainder of the surplus will be transferred to the health insurance fund for redistribution.

5. In the case where the allocated funding is in deficit within the year, the health facility shall use its revenues to cover the deficit as stipulated; if the health facility’s allocated funding is in deficit for two consecutive years, a review for adjustment in the following year shall be considered.

6. The Minister of Health shall identify diseases, groups of diseases, medical services, and costs not covered at the fixed rates, provide technical guidance for the identification and the implementation of fixed rate-based reimbursement.

7. The Ministry of Health shall take charge and cooperate with the Ministry of Finance in regulating the allocation of fixed funding, managing the surplus funding, determining the portion of surplus funds that health facilities may retain, and establishing the fixed rate-based reimbursement schedule.

Article 41. Method of diagnosis-related group reimbursement

1. Diagnosis-related group (DRG) reimbursement is a predetermined cost payment method for each group of diagnoses that are similar in clinical characteristics and required resources, regardless of the actual costs incurred during health insurance-covered medical care.

2. The scope of diagnosis-related group reimbursement includes costs for medical care within the insurance coverage and reimbursement rates for individuals with health insurance cards when receiving inpatient medical care and day treatment.

3. The Minister of Health stipulates the scope of data to be used in the development of payment methods according to DRG, the DRG list; principles, methods, techniques for developing and adjusting the DRG classification algorithm and cost accounting to calculate payment parameters according to DRG, determine cost levels, and the total DRG fund; guidelines for organizing implementation, and the payment roadmap based on diagnosis groups.

4. The Vietnam Social Security determines the DRG list, estimates the total DRG costs, relative weight, base rate, and adjustment coefficient in accordance with the provisions of Clause 3 of this Article, and submits them to the Ministry of Health for issuance. At the same time, they provide the data on medical care costs used in the development of DRG for storage and for serving the tasks of appraisal and issuance.

Article 42. Application of payment methods

1. The health insurance-covered medical care costs for medical care services that have been reimbursed under one payment method shall not be reimbursed again under another payment method.

2. The payment methods applicable at the health facility are specifically stated in the provider contract with the social security authority, in accordance with the provisions of Article 25 of this Decree.

Chapter VIII

PAYMENT OF MEDICAL CARE COSTS BETWEEN THE SOCIAL SECURITY AUTHORITY AND THE HEALTH FACILITY

Article 43. Payment for costs of medicines and medical equipment transferred between health insurance-covered health facilities

The health insurance fund shall cover the costs of drugs and medical equipment that are transferred between health insurance-covered health facilities in cases where, at the time the patient is prescribed or instructed to use drugs or medical equipment, such items are not available and cannot be replaced by other drugs or medical equipment, as detailed below:

1. Health facilities that do not have available drugs or medical equipment at the time of prescription or indication and which cannot be substituted with other drugs or medical equipment shall be determined as follows:

a) Health facilities that do not have any commercial drugs containing the active ingredient prescribed to the patient, or have drugs with the same active ingredient but in different concentrations, dosages, formulations, or routes of administration that cannot be substituted for the prescription;

b) Health facilities that do not possess medical equipment which patients have been prescribed to use, and do not have equipment to replace it, with the exception of in vitro diagnostic medical devices, personal specific medical equipment, and medical devices included in the list of medical devices issued by the Minister of Health that are bought and sold like ordinary goods in accordance with the provisions of Decree No. 98/2021/ND-CP dated November 8, 2021 of the Government on the management of medical equipment, which is amended and supplemented by Decree No. 07/2023/ND-CP dated March 3, 2023, and Decree No. 04/2025/ND-CP dated January 1, 2025 of the Government.

2. At the time when the patient is prescribed and indicated for treatment, the health facility does not have the necessary drugs or medical equipment available due to one of the following reasons:

a) During the group-A epidemic phase, the health facility is subject to blockade, medical isolation, or is located in areas subject to implementation of social distancing measures or performance of tasks for epidemic prevention and control;

b) The health facility is in the process of selecting a contractor in accordance with the approved contractor selection plan by: competitive bidding or limited bidding or shopping or direct purchasing or contractor selection in special cases but no contractor has been selected, or online bidding or online purchasing and has carried out simplified direct contracting in accordance with the law on bidding but no contractor has been selected;

c) The health facility has signed a contract with the contractor supplying drugs and medical equipment; however, at the time of prescribing the drugs or medical equipment for the patient, there is documentary evidence confirming that the contractor is unable to supply the drugs (such as a document on the drug supply from the supplier, contract’s addendum, or a record confirming the contractor's inability to provide the drugs).

3. The authority to decide cases of receiving drugs and medical equipment transferred from other health insurance-covered health facilities is stipulated as follows:

a) The director of the health facility where the patient is receiving treatment shall, based on their decision on the actual situation and the conditions specified in clauses 1 and 2 of this Article, select a health insurance-covered facility equipped with available drugs and medical equipment and agreeing to transfer.

b) Health facilities for transferring drugs and medical equipment must be selected in an appropriate, cost-effective and efficient manner; encouraging the transfer of drugs and medical equipment among health facilities located within the same province or central-affiliated city.

4. The transfer of and payment for drugs and medical equipment shall be carried out as follows:

a) The health facility is responsible for notifying the transfer of drugs, medical equipment, and the costs that the patient participating in health insurance must bear in the event that the patient is required to pay additional expenses beyond the co-payment stipulated by regulations.

b) The facility transferring drugs and medical equipment and the facility receiving them shall prepare a written receipt;

c) The health insurance fund shall reimburse the costs of drugs and medical equipment within the scope of benefits and reimbursement rates for participants in health insurance as stipulated to the health facility where the patient is received, based on the reimbursement rates of the health insurance for the facility transferring the drugs and medical equipment. Other expenses paid by the patient to the health facility where the patient received treatment;

d) The health facility receiving drugs and medical equipment shall pay costs of the drugs and medical equipment to the transferring health facility. The health facility that provide care for the patient shall consolidate the costs of drugs and medical equipment covered by the health insurance fund into the medical care costs of the patient for reimbursement from the social security authority.

dd) The social security authority is responsible for publishing the number of unused drugs and medical equipment according to the successful bidding results of health insurance-covered health facility on the data reception portal of the Vietnam Social Security, for the health facility to refer to the request for the transfer of drugs and medical equipment.

5. In the case where a patient participating in health insurance does not agree to pay costs outside the health insurance coverage and the reimbursement rates of health insurance participants when transferring drugs and medical equipment, the health facility shall refer the patient to another health facility that ensures the provision of drugs and medical equipment for the patient's treatment.

Article 44. Regulations on the transfer of patients or human biological specimens to other facilities that meet the conditions for performing paraclinical services

1. Health facilities are permitted to transfer patients or human biological specimens only to receiving facilities approved by competent authorities that they meet the conditions necessary for conducting paraclinical services. The facility receiving patients or human biological specimens for performing paraclinical services is not allowed to forward patients or human biological specimens to a third party.

2. The implementation of paraclinical services shall be transferred in accordance with technical expertise requirements in medical care, ensuring the rights of health insurance participant and be applicable in cases such as the following:

a) The paraclinical services are approved by the competent state authority for health facilities and are being implemented at those facilities. However, at the time of the designation for use by patients, the health facility is unable to provide or is insufficient to meet the full demand for the execution of paraclinical services. The health facility that transfers patients or human biological specimens shall complete the Form No. 9 in the Appendix attached to this Decree in order to send it along during the transfer of patients or biological specimens to the facility performing paraclinical services. The health facility where patients or specimens are transferred must send a list of the paraclinical services performed to the facility conducting the paraclinical services for the health security authority that has signed the provider contract, in order to serve as the basis for payment.

b) Paraclinical services have not yet been approved by the competent state authority for the health facility, but are actually necessary for professional activities and are included in the list issued by the Minister of Health. The head of the health facility with health insurance, where patients or specimens are transferred, shall base on the functions, tasks, and scope of professional activities approved by the competent authority to compile a list of paraclinical services that need to be transferred and sign a framework contract with the facility performing paraclinical services. The framework agreement contains a consensus that the social insurance agency, where the provider contract is signed with the health facility where the referral is made, is responsible for the verification of the paraclinical services that have been received and performed at the facility providing paraclinical services. The health facility that transfers the patient or specimens shall send a list of the necessary paraclinical services along with a framework contract to the social insurance agency where the provider contract was signed before performing the services.

3. The health facility, upon transferring the patient or the specimen, is responsible for settling the costs with the health facility or unit providing the service. At the same time, it must consolidate the costs of the clinical services into the expenses of the patient's examination and treatment for reimbursement with the social insurance agency. The receiving facilities providing paraclinical services are not allowed to charge additional fees for the examination of patients. In cases where patients are required to pay additional costs for the implementation of paraclinical services beyond the co-payment costs as stipulated, the health facility transferring the patient or the specimen must inform and obtain the patient's consent prior to the transfer of the patient or the specimen.

4. The health insurance fund reimburses the costs of paraclinical services according to the scope and benefits of health insurance participants, specifically as follows:

a) In the case specified in point a, clause 2 of this Article: the health insurance fund shall reimburse according to the cost of clinical services that have been approved by the competent authority for the facility where the clinical service is performed, but shall not exceed the medical care service charge of the referring facility. In the case where the facility providing the paraclinical services has not been approved by the competent authority or does not have a health insurance-covered medical care service charge, the health insurance fund will provide reimbursement based on the price of technical services approved by the competent authority for the health facility where the patient or specimen is transferred.

b) In the case specified in point b, clause 2 of this Article: the health insurance fund shall provide reimbursement according to the paraclinical service charges that have been approved by the competent authority for the facility where the paraclinical services are performed. In cases where the facility providing paraclinical services has not been approved by the competent authority for the health insurance-covered medical care service charges, the health insurance fund will provide reimbursement according to the technical service prices approved by the competent authority for public health facilities, applying the payment principles specified in points a, b, c, and d of Clause 2, Article 47 of this Decree.

Article 45. Payment of medical care costs during the process of technical transfer

1. Payment of medical care costs during the technical transfer process carried out by the personnel of the health facility in accordance with the technical transfer proposal and the technical transfer contract as stipulated by the law on medical examination and treatment.

2. The health facility receiving the transferred technology is responsible for notifying in writing the social insurance agency that signs the provider contract about the medical care services conducted in accordance with the scheme and transfer contract, serving as the basis for payment, as well as the approval document from the competent authority for special techniques. The health insurance fund reimburses according to the quantity of medical care services outlined in the project, contract, or transfer documents or approval papers from authorized levels regarding special technical services.

3. The payment rates for the medical care services included in the list of services paid by the health insurance fund shall be approved by competent authorities for the health facilities that transfer technology. In the case where a health facility that transfers technology is a private health facility, it shall be implemented according to the provisions at point b, clause 2, Article 39 of this Decree.

4. For medical care costs that are covered by the health insurance fund but have not been included in the medical care service charge structure, the health insurance fund shall reimburse in accordance with the provisions of Clause 3, Article 39 of this Decree.

5. After completing the implementation of the contract for the transfer of health facilities, it is necessary to submit the technical list and price approval to the competent authority in accordance with the regulations of the law on the medical care service charge to serve as the basis for payment for that technical service.

Article 46. Payment for medical care costs at health facilities that provide health insurance services outside of working hours or on holidays

1. Individuals holding health insurance cards seeking medical care will be reimbursed by the health insurance fund within the health insurance coverage and reimbursement rates.

2. Health facilities are responsible for ensuring adequate human resources and professional conditions, publicly disclosing the costs that patients must pay beyond the health insurance coverage and the reimbursement rates, and must notify patients in advance; they are required to provide written notifications to the relevant state health management authority in the area and the social insurance agency where the provider contract is signed at least three working days prior to conducting healthcare services outside of regular hours or on holidays and weekends, to serve as a basis for performing and reimbursing healthcare costs.

Article 47. Payment of medical care service costs in health insurance for private health facilities

1. The reimbursement rates for medical care services covered by the health insurance fund shall be implemented in accordance with the provisions of Article 39 of this Decree.

2. In the case of private health facilities applying the payment rates for medical care costs of the health insurance fund as stipulated in point b of clause 2, Article 39 of this Decree, the implementation shall proceed as follows:

a) Tertiary health facilities are reimbursed based on actual costs, but not exceeding the highest charge of that medical care service of a state-run tertiary health facility in the province, or the state-run secondary health facility in the province in cases where there is no price from a state-run tertiary health facility in the province.

b) Secondary health facilities shall be provided with reimbursement based on actual costs, but not exceeding the highest charge of those care services offered by other state-run secondary health facilities in the same province. In the case where the state-run secondary health facility in the province does not have a price for the examination and treatment service, the payment shall be made at most at the lowest price of that technical service at the state-run tertiary health facility in the province.

c) Primary health facilities shall be provided with reimbursement according to the actual costs, but not exceeding the highest charge of those medical care services provided by other state-run primary health facilities within the same province. In cases where the state-run primary health facilities within the province do not have set charges of those medical care services, the reimbursement shall be capped at the minimum medical care service charge provided by the state-run secondary health facilities in the province.

d) In cases where the medical care service charge has not yet been determined or approved by the competent authority for state-run health facilities in the province, private health facilities shall be reimbursed according to the principles stipulated in points a, b, and c of this clause based on the medical care service charge approved by the competent authority for state-run health facilities in one of the neighboring provinces. In cases where state-run health facilities in bordering provinces do not have the medical care service charge approved, payment shall be made according to the service charge approved by the competent authorities for state-run health facilities in other provinces nationwide.

Article 48. Reimbursement rates in cases where technical services have been prescribed and carried out by health facilities, but due to the progression of diseases or the physical conditions of patients, the techniques cannot be continued

1. The health insurance fund shall reimburse based on the actual quantity of drugs, medical equipment, gases, supplies, tools, instruments, and chemicals used to perform the technical services for which the health insurance fund is paying for the health facility, at the purchase prices as stipulated by the law on bidding; for blood and blood product costs, reimbursement shall be governed by regulations set forth by the Minister of Health.

2. The health insurance fund shall cover the salary, wages, allowances, contributions, and surgical allowances (if any) at the rates stipulated by the Minister of Health, in accordance with the pricing structure of the technical services for which the facility is receiving payment from the health insurance fund.

Article 49. The payment of costs of medicines, chemicals, testing materials, and medical equipment for health facilities that are public service providers self-covering their recurrent expenditures and investment expenditures, public service providers self-covering their recurrent expenditures, and private health facilities falling under the case specified in Clause 3, Article 55 of the Law on Bidding in 2023, which is amended and supplemented by Law No. 90/2025/QH15

In the case where a health facility that is a public service provider self-covering its recurrent expenditures and investment expenditures, a public service provider self-covering its recurrent expenditures, or a private health facility does not choose to apply the regulations of the Law on Bidding for the purchase of drugs, chemicals, testing materials, medical equipment, and falls under the case of payment as specified in Clause 3, Article 39 of this Decree, the health insurance fund shall make payments within the health insurance coverage and reimbursement rates of health insurance participants based on the purchase unit price, but not exceeding the unit price determined by the contractor selection results that are still valid at the time of payment for drugs of the same trademark, manufacturer, origin, concentration, dosage, route of administration, technical criteria group, dosage form, unit of measurement, or for chemicals, testing materials, medical devices of the same manufacturer, origin, and technical criteria, according to the principles and priorities as follows:

1. Results of the national centralized procurement and results of price negotiations.

2. Results of centralized shopping in the province.

3. Purchasing results of state-run health facilities with the same professional classification in the same province as the health facility.

4. In cases where the unit price specified in Clause 3 of this Article is not determined, the health insurance fund shall reimburse based on the following principles:

a) The primary health facility shall be reimbursed at the lowest successful bid from the state-run secondary health facility in the same province In cases where the successful bid of the state-run secondary health facility is not available, the health facility shall be reimbursed at the lowest successful bid from the state-run tertiary health facility in the same province;

b) The primary health facility shall be reimbursed at the lowest successful bid from the state-run primary health facility in the same province. In cases where the successful bid of the state-run primary health facility is not available, the health facility shall be reimbursed at the lowest successful bid from the state-run tertiary health facility in the same province;

c) The tertiary health facility shall be reimbursed at the lowest successful bid from the state-run primary/secondary health facility in the same province.

5. In case where the unit price specified in clause 4 of this Article is not available, the health insurance fund shall make reimbursement according to the successful bid from the state-run health facility and the results of concentrated procurement in the neighboring province in the following order of priority:

a) According to the results of centralized procurement in the province.

b) Purchasing results of state-run health facilities with the same professional classification as the health facility;

c) According to the principles stipulated in points a, b, and c of Clause 4 of this Article.

6. In case where the unit price specified in clause 5 of this Article is not determined, the health insurance fund shall make reimbursement according to the successful bid from the state-run health facility and the results of concentrated procurement in the other province nationwide according to the principles set forth in points a, b, and c of Clause 5 of this Article.

Article 50. Payment of medical care costs in certain cases

1. Payment of medical care costs for children under 6 years old and individuals who have donated organs but do not have health insurance cards:

a) Health facility shall look up the temporary health insurance card number on the Data reception portal of the Vietnam Social Security to obtain information about the temporary health insurance cards, compile statement of the health insurance-covered medical care costs according to the health insurance coverage and reimbursement rates and submit this information to the social security authority for payment in accordance with regulations. In the case where the patient has not been issued with a temporary card, the health facility shall enter the complete information on the Data reception portal of the Vietnam Social Security in order for the Portal to automatically issue a temporary card;

b) The social security authority is responsible for verifying the information of the temporary health insurance card; and for processing the payment of medical care costs in accordance with regulations.

2. In the case of transferring a patient to another health facility, if the patient requires accompanying medical personnel and the use of drugs and medical equipment as per professional requirements during transportation, the costs of drugs and medical equipment will be included in the treatment costs of the referring/transferring health facility.

3. In cases where a patient has been stabilized after inpatient treatment but need to continue medication after discharge as prescribed by the health facility, the health insurance fund shall cover the cost of medications within the health insurance coverage and reimbursement rates as stipulated by the Minister of Health. The health facility shall add this medication cost to the patient's medical care cost before they get discharged.

4. In cases where a patient requires medical care and their health insurance card is still valid, but during inpatient treatment, day treatment, or outpatient treatment at the health facility, the health insurance card has expired, the health insurance fund will reimburse the medical care costs within the health insurance coverage and reimbursement rates until the patient is discharged for a maximum of 15 days from the expiry date of the health insurance card. Upon discharge from the hospital and completion of the occasion of service, the patient is responsible for continuing to pay the health insurance premiums for the period following the expiration of their health insurance card.

5. The medical care costs for cases where a health insurance participant requires medical care before January 1 and completes the occasion of service, or discharges from hospital on or after January 1 of the following year shall be processed as follows:

a) In the case that a health facility renews the provider contract, the medical care costs shall be included in the medical care costs of the following year.

b) In the case that a health facility refuses to renew the provider contract, the medical care costs shall be included in the medical care costs of the preceding year.

6. In the case where a patient possesses a health insurance card and presents the card late, the health insurance fund will reimburse the costs of medical care within the scope of benefits and reimbursement rates from the time the health insurance card is presented. The costs of medical care during the period when the patient has not presented their health insurance card will be reimbursed directly according to the procedures specified in Article 56 and the reimbursement rates specified in Article 57 of this Decree.

Article 51. Denial of payment of health insurance-covered medical care costs

1. The denial of payment of health insurance-covered medical care costs is when the social security authority declines to pay health insurance-covered medical care costs that are found to be noncompliant with laws on health insurance and medical care during the appraisal process and before payment to the health facility.

2. Upon denial of payment, it is required to specify the basis, reasons for the refusal, and the amount of denied claims in the assessment record, including all medical care costs proposed for reimbursement by the social security authority by electronic means that are automatically processed when the health facility submits the data. Representatives of the social security authority and representatives of the health facility shall reach an agreement to sign the record of the verification of health insurance-covered medical care costs, which serves as the basis for settlement within the timeframe specified in point b, clause 2, Article 32 of the Law on Health Insurance.

3. Health facilities have the right to petition social security authorities to reconsider the denial of payment of health insurance-covered medical care costs, or to petition competent authorities to review and resolve matters in accordance with legal provisions.

Article 52. Recovery of health insurance-covered medical care costs

1. Health insurance-covered medical care costs shall be recovered in cases where they have been paid but are found to be inconsistent with the legal provisions through inspections, audits, resolution of issues, and handling of legal violations by the competent authorities and discovered during the process of implementation.

2. Based on the conclusions and the processing results of the competent authorities as stipulated in Clause 1 of this Article, the directors of the social security authorities shall issue a document on the recovery of the health insurance-covered medical care costs under their jurisdiction. The document must clearly state the legal basis for the recovery, the content of the violation, the amount of costs being recovered, the deadline for the recovery, and the responsibilities of the organizations and individuals related to the recovered costs. The health facilities are responsible for returning the recovered costs to the health insurance fund.

3. The recovered costs shall be recorded in the year the recovery takes place.

4. Health facilities have the right to petition social security authorities to reconsider the recovery of health insurance-covered medical care costs, or to petition competent authorities to review and resolve matters in accordance with legal provisions.

5. For the recovery of health insurance-covered medical care costs after inspections, audits, and handling of legal violations by competent state authorities, if there are regulations different from this provision, those regulations shall apply.

Article 53. Responsibilities of the parties involved in the denial of payment and the recovery of health insurance-covered medical care costs

1. Agencies, organizations and individuals that are denied payment or requested to refund health insurance-covered medical care costs are obliged to comply with the decisions of social security authorities or the final resolutions of the competent authorities as stipulated by law.

2. When addressing the payment denial and the recovery of health insurance-covered medical care costs, resolving authorities must clearly determine the responsibility and the handling or recommendation for handling the responsibility of the relevant agencies, organizations, and individuals in accordance with the law.

3. In the event of a denial of payment or a recovery not in accordance with the law, the social security authority that refuses payment or is subject to recovery shall be responsible for supplementary payments and reimbursements to the health facility.

Chapter IX

DIRECT PAYMENT OF MEDICAL CARE COSTS BETWEEN SOCIAL SECURITY AUTHORITIES AND PARTICIPANTS IN HEALTH INSURANCE

Article 54. Cases in which social security authorities directly pay health insurance-covered medical care costs to holders of health insurance cards in accordance with point c, clause 2, Article 31 of the Law on Health Insurance

A social security authority shall directly pay medical care costs to a participant in health insurance within the insurance coverage and reimbursement rates as stipulated by the law on health insurance in the following cases:

1. The patient is in a critical condition, unconscious or deceased, and has not provided health insurance card prior to discharge.

2. The participant in health insurance under the management of the Ministry of Defense and the Ministry of Public Security who has lost their health insurance card but has not yet been reissued, or whose health insurance card information contains errors or discrepancies that have not been corrected by the social security authority at the time of completing the occasion of service, or discharge from the hospital.

3. Participants in health insurance who have health insurance premiums paid by state budget but have not yet been issued with a health insurance card, exclusing those in the cases specified in Clause 1, Article 50 of this Decree. Patients will be reimbursed for the full amount of medical care costs within the health insurance coverage and the reimbursement rates starting from the date they are determined to be covered by the state budget, but have not yet been reimbursed due to not having been issued a health insurance card.

4. The patient was admitted for emergency treatment at a health facility that does not have a provider contract. Patients are reimbursed for the entire cost of medical care within the health insurance coverage and the reimbursement rates that has not yet been reimbursed according to the regulations of the law on health insurance.

5. In the case of medical care under health insurance for individuals who have changed to a group with a higher level of health insurance benefits but have not yet been issued with a new health insurance card, the social security authority will reimburse the difference in costs between the two benefit levels directly to the health insurance participant.

6. In cases where patients purchase medications and medical devices on their own as prescribed in Articles 58 and 59 of this Decree. For individuals subject to the provisions delineated in points a, b, c, and d of clause 3, Article 12 of the Law on Health Insurance, the payment for costs related to pharmaceuticals and medical devices shall be carried out in accordance with the regulations set forth in Decree No. 70/2015/ND-CP dated September 1, 2015, issued by the Government, detailing and guiding the implementation of certain articles of the Law on Health Insurance applicable to the army, the police, and individuals involved in cryptography work, as amended by Decree No. 74/2025/ND-CP dated March 31, 2025.

7. In cases where a health insurance participant seeks medical care during the period of their card being revoked, temporarily confiscated, or temporarily invalidated as stipulated in clauses 1, 2, and 3 of Article 12 of this Decree, and it is not due to the fault of the health insurance participant, the patient shall be entitled to full reimbursement of the medical care costs within the insurance coverage and reimbursement rates appropriate to their category.

Article 55. Applications for direct payment

1. A written request for direct payment made using the Form No. 10 provided in the Appendix enclosed herewith.

2. The documents are photocopies that include:

a) Health insurance card or health insurance code in cases where there is information about the electronic health insurance card, identity verification document as prescribed in point b, clause 1, Article 37 of this Decree. In the case specified in Clause 5 of Article 54 of this Decree, the health insurance card includes both the card with the old reimbursement rate and the card with the new reimbursement rate that is higher than the old one;

b) Hospital discharge note or medical examination form or medical examination log of the visit for which payment is requested (a copy with the official seal of the health facility);

c) Prescription (if available).

3. Invoice and cost statement.

4. In the case specified in Clause 6 of Article 54 of this Decree, the application for direct payment, in addition to the provisions of Clauses 2 and 3 of this Article, shall also include the following documents:

a) Medical device prescription form for patients in the case of medical device prescription;

b) The confirmation form of the shortage of drugs and medical equipment made using Form No. 11 of the Appendix enclosed with this Decree by the health facility to the patient.

Article 56. Direct payment procedures

1. The patient or the patient's relatives, as stipulated by law regarding examination and treatment, must fully declare the information in the direct payment request form according to Form No. 10 attached to this decree (including the option to receive payment directly at the one-stop division of the social security authority or through the personal account number declared in Form No. 10). At the same time, they must submit the documentation as required in Sections 2, 3, and 4 of Article 55 of this decree via the National Public Service Portal or through the application of the social security authority, or submit directly at the one-stop shop, or send it by postal service to the social security authority in the area where the patient resides, or to the social security authority where the insurance card was issued, or to the social security authority that has entered into a provider contract with the health facility where the patient is being treated.

2. The national public service portal or through the application of the social security authority automatically issues a receipt of the application and schedules the direct payment result for the patient or their relatives, or for the staff receiving the application at the one-stop department of the social security authority, who directly checks the documents and issues the receipt of the application and schedules the direct payment result for the patient or their relatives.

3. In the absence of any request for amendments or supplements to the application, within 25 days from the receipt of a complete and valid application (in case of submitting a physical application, based on the date recorded on the received date stamp or the receipt of application), the social security authority must complete the health insurance assessment and settle payments for the patient. The direct payment costs shall be paid in cash or by bank transfer to the account number provided by the patient in the written request for direct payment.

4. In the event of a request for amendments or additions to an application, the following procedures shall be followed:

a) Within 05 working days from the receipt of the application (in the case of submitting a physical application, based on the date recorded on the received date stamp or the receipt of application), the social security authority shall prepare a document specifying the content that needs to be amended or supplemented and send it to the patient or the relative of the patient;

b) Within 20 days from the receipt of the written request for amendments or additions to the application (in the case of submitting a physical application, based on the date recorded on the received date stamp or the receipt of application), the patient or the relative of the patient is responsible for amending or supplementing the application and sending it to the social security authority for consideration;

c) Within 20 days from the receipt of a complete and valid application (in case of submitting a physical application, based on the date recorded on the received date stamp or the receipt of application), the social security authority must pay costs to the patient. The direct payment costs shall be paid in cash or by bank transfer to the account number provided by the patient in the written request for direct payment.

Article 57. Reimbursement rates for direct payment in the cases stipulated in point a and point b, clause 2, Article 31 of the Law on Health Insurance.

1. In the case where a patient seeks medical care at a secondary health facility that, prior to January 1, 2025, has been determined by the competent authority as a district level or a secondary health facility that has scored below 50 or has been temporarily classified as a secondary health facility, except for secondary health facilities that, before January 1, 2025, have been identified by the competent authorities as provincial level health facilities and do not have a provider contract (except in emergency cases), the reimbursement rate shall be as follows:

a) In the case of outpatient medical care, the health insurance fund shall make reimbursement according to the actual costs within the health insurance coverage and the reimbursement rates as stipulated, but shall not exceed 0,15 times the statutory pay rate at the time of the medical care;

In the case of inpatient medical care, the health insurance fund shall make reimbursement according to the actual costs within the health insurance coverage and the health insurance reimbursement rates as prescribed, but not exceeding 0,5 times the statutory pay rate at the time of discharge.

2. In the case where a patient seeks inpatient medical care at a secondary health facility that has been designated by the competent authority as a provincial level or a secondary health facility that has scored between 50 and just under 70 points before January 1, 2025, and does not have a provider contract (except in emergency cases), the health insurance fund shall make reimbursement according to the actual costs within the health insurance coverage and the reimbursement rates as regulated, but not exceeding 1,0 times the statutory pay rate at the time of discharge.

3. In the case where a patient seeks outpatient or inpatient treatment at a tertiary health facility without any provider contract (except in emergency situations), the health insurance fund shall make reimbursement according to the actual costs within the health insurance coverage and the reimbursement rates specified, but not exceeding 2,5 times the statutory pay rate at the time of discharge.

4. In cases where a patient seeks medical care not in accordance with the provisions of Clause 1, Article 28 of the Law on Health Insurance, fails to present health insurance card, or provides this information late before the end of the occasion of service or discharge, except in the cases specified in Clause 1, Article 54 of this Decree and Clause 5 of this article, the health insurance fund shall make reimbursement according to actual costs within the health insurance coverage and the reimbursement rates during the period the patient has not presented the health insurance card, but not exceeding the specific limits as follows:

a) In the case of outpatient medical care, the maximum reimbursement rate shall not exceed 0,15 times the statutory pay rate at the time of receiving medical care;

b) In the case of inpatient medical care, the maximum reimbursement rate shall not exceed 0,5 times the statutory pay rate at the time of discharge.

5. During the time when the patient has not presented the health insurance card as specified in Clause 1, Article 38 of this Decree, the participants defined in Points a, b, c, d, and dd, Clause 3, Article 12 of the Law on Health Insurance are entitled to have their medical care costs covered by the health insurance fund within the scope of benefits and reimbursement rates.

Article 58. Medicines and medical devices that are eligible for direct reimbursement to patients when they purchase them independently.

1. The medication is classified as a rare drug on the List of Rare Drugs of the Minister of Health.

2. Medical devices of type C or D, excluding in vitro diagnostic medical devices, personal specific medical devices, and medical devices included in the list of medical devices issued by the Minister of Health, can be bought and sold like ordinary goods according to the provisions of Decree No. 98/2021/ND-CP dated November 8, 2021 of the Government on the management of medical devices, which was amended and supplemented by Decree No. 07/2023/ND-CP dated March 3, 2023 and Decree No. 04/2025/ND-CP dated January 1, 2025 of the Government.

Article 59. Conditions for direct payment of costs to patients in cases where patients purchase medicines and medical devices themselves

At the time of prescribing, the indication of medication and the indication for the use of medical devices must meet all the conditions as stipulated below:

1. At the time the patient is prescribed and indicated, the health facility does not have the medication or medical equipment available as required by point b, clause 2, Article 43 of this Decree and falls under the following circumstances:

a) Regarding medication: there is no commercial drug containing the active ingredient that the patient is prescribed, or the same active ingredient but in different concentrations, dosages, formulations, or routes of administration, and it cannot be substituted for prescribing to the patient.

b) For medical devices: there is no medical device that the patient is prescribed to use and there is no medical device to substitute.

2. Patients cannot be transferred to another health facility in the following cases:

a) The health status and medical conditions of the patient are determined to be insufficient for transfer;

b) Health facilities where patients are being examined and treated while being in a medical isolation period as mandated by the law on the prevention and control of infectious diseases;

c) The health facility where the patient is being examined and treated is a tertiary health facility or the highest professional health facility within the province or central-affiliated city.

3. It is not permissible to transfer medication and medical equipment between health facilities.

4. Prescription medications and medical devices must be indicated for use in accordance with the scope of expertise of the health facility.

5. Medications and medical devices that are prescribed and indicated for use must fall within the scope of benefits for health insurance participants and have had their medical care costs reimbursed at one of the health facilities nationwide.

6. Health facilities are responsible for providing a certificate confirming the shortage of medicines and medical equipment according to Form No. 11 in the Appendix issued together with this Decree to patients as a basis for payment.

Article 60. Rates of direct payment of costs to patients in cases where patients purchase medicines and medical devices themselves

1. The social security authority shall reimburse patients directly according to the following regulations:

a) Regarding medications: the basis for calculating the payment amount is the quantity and unit price stated on the invoice provided by the patient when purchasing from the pharmaceutical business. In cases where the medicine has regulations regarding the payment ratio and conditions, these shall be implemented according to the ratio and payment conditions.

b) For medical devices: the basis for calculating the payment amount is the quantity and unit price stated on the invoice issued by the patient when purchasing from the medical device sales establishment. In cases where medical devices have established payment limits, the payment shall not exceed the prescribed payment limit for that medical device.

2. The unit price of drugs and medical equipment serves as the basis for determining the payment level, which must not exceed the payment price at the closest time when payment is made for drugs and medical equipment that have been contracted at the health facility where the patient has received medical care.

In cases where the drugs and medical devices have not been successfully contracted at the health facility where the patient has received treatment, the unit price used to determine the health insurance reimbursement rate is based on the contractor selection result that is still valid at the time of reimbursement, in the following order of priority:

a) The results of national centralized procurement or the results of price negotiations;

b) Results of local centralized procurement within the area;

c) The result of selecting the lowest bidder from the state-run health facilities of the same level of technical expertise in the area. In cases where there is no contractor selection result from the state-run health facilities of the same professional classification in the area, based on the lowest contractor selection results from other state-run health facilities in the area;

d) The lowest contractor selection results at the time of reimbursement for state-run health facilities with the same professional classification nationwide. In cases where there is no contractor selection result from state-run health facilities with the same professional classification nationwide, the selection shall be based on the lowest contractor selection result from other state-run health facilities across the country.

3. The social security authority shall deduct the medical insurance costs paid by the health facility where the patient is being treated as follows:

a) In the case where the costs of medication and medical equipment are included in the medical care service charge: a deduction shall be made from the costs of medical care services covered by health insurance at the reimbursement rates specified in clauses 1 and 2 of this Article;

b) In cases where the costs of medication and medical equipment are not included in the medical care service charge: no deductions shall be made from the health insurance-covered medical care service costs for the health facility;

c) The costs of medications and medical equipment that are directly paid by the social security authority to the patients are included in the projected expenditure of the health facility.

Chapter X

MANAGEMENT AND USE OF HEALTH INSURANCE FUND

Article 61. Allocation and use of health insurance premiums

1. 92% of the health insurance premiums for medical care (hereinafter referred to as the medical care fund) shall be allocated to:

a) Cover the expenses within the health insurance coverage of participants in health insurance in accordance with the regulations of the law on health insurance;

b) Reallocate to educational institutions or vocational education institutions, agencies, organizations, and enterprises that meet the conditions specified in Article 63 of this Decree.

2. 8% of the health insurance premiums shall be allocated to the reserve fund and the expenditures for the organization and operation of health insurance as stipulated below:

a) The reserve fund allocation is the amount remaining after the allocation for the organization and operation of health insurance as stipulated in point b of this clause, and must be at least 4% of the health insurance premiums;

b) The organization and operation of health insurance shall be capped at 4% of the total health insurance premiums. After the Social Insurance Management Council approves the annual settlement of the organization and operation of social insurance, unemployment insurance, and health insurance, the Vietnam Social Security is responsible for adding any unutilized funds into the reserve fund for general adjustment. The Prime Minister has decided the expenditure levels for the organization and operation of health insurance for each specific year.

Article 62. Expenditure levels for medical care in the primary healthcare system.

1. The amount allocated to the educational institution or vocational education institution includes:

a) Allocation of 5% of the health insurance revenue calculated on the total number of children under 6 years old or students currently enrolled in educational institutions, the calculation formula is as follows:

The allocation amount = 5% x (N _{Number of individuals} x M _{Health insurance premium} x L _{Statutory pay rate} x Th)

Where:

- N _{Number of individuals:} The total number of children under 6 years of age; students who are currently enrolled in educational institutions or vocational education institutions that participate in health insurance.

- M _{Health insurance premiums:} The applicable health insurance premium rate for children under 6 years old or students, as stipulated in clauses 3 and 4 of Article 6 of this Decree.

- L _{statutory pay rate}: The statutory pay rate at the time of health insurance contribution.

- Th: Number of months during which health insurance premiums are paid.

Every 3, 6, or 12 months, the social security authority is responsible for transferring the specified amount to educational institutions or vocational education institutions and consolidating it into the final settlement of the health insurance-covered medical care fund.

b) Allocation of 1% from the monthly health insurance premiums for employees at educational institutions or vocational education institutions. The social security authority is responsible for disbursing this payment immediately upon receiving the health insurance premiums from the educational or vocational education institution.

2. The amount retained for agencies, organizations, and enterprises that meet the conditions specified in Clause 1, Article 63 of this Decree is 1% calculated based on the monthly health insurance contributions for employees at those agencies, organizations, and enterprises. The social security authority is responsible for disbursing this payment immediately after receiving the health insurance contributions from the agencies, organizations, and enterprises.

3. The amount retained for the workers on the offshore fishing vessel:

a) The allocation of 10% of the health insurance revenue calculated based on the number of workers on the ship who are participating in health insurance for the purpose of purchasing medicine cabinets, drugs, medical equipment, and tools and instruments for first aid and initial treatment. The calculation formula is as follows:

The allocation amount = 10% x (N _{Number of individuals} x M _{Health insurance premium} x L _{Statutory pay rate} x Th)

Where:

- N _{Number of individuals}: The number of paticipants in health insurance working on fishing vessels.

- M _{Health insurance premiums:} The health insurance premium rates for the first person in the household is regulated in Article 6 of this Decree.

- L _{statutory pay rate}: The statutory pay rate at the time of health insurance payment.

- Th: Number of months during which health insurance premiums are paid.

b) The chairman of the provincial people's committee organizes the procurement and distribution of medical cabinets, medicines, medical equipment, and tools to offshore fishing vessel owners. The social security authority shall transfer the amount of money specified in point a of this clause to the agency or organization designated by the Chairperson of the provincial People's Committee to purchase medicine cabinets, drugs, medical equipment, and tools; and consolidate the transferred amount into the final settlement of the medical care fund.

4. Based on actual needs and the ability to balance the health insurance fund, the Minister of Health submits to the Government a proposal to adjust the allocation of funds for medical care in the primary healthcare system.

Article 63. Conditions and content of expenditure, settlement of funds for medical care in primary healthcare work.

1. Educational institutions or vocational education institutions, agencies, organizations, and enterprises (excluding educational institutions or vocational education institutions, agencies, organizations, and enterprises that have signed provider contracts in accordance with Article 30 of this Decree) that are allocated funding from the health insurance fund to carry out medical care in primary healthcare must meet the following conditions:

a) There is at least one person qualified to work full-time or part-time in primary healthcare as stipulated in Article 19 of the Law on Examination and Treatment.

b) There shall be a medical room or separate workspace to carry out first aid and initial treatment for individuals under the management of educational institutions or vocational education institutions, agencies, organizations, or enterprises in the event of accidents, injuries, or common illnesses during the time of study or work at these institutions.

2. Expenditure items:

a) Purchase of medicine, medical equipment, supplies, tools, instruments, and chemicals for first aid and initial treatment for children, students, and individuals managed by agencies, organizations, and enterprises in the event of accidents or common illnesses during their time studying or working at educational institutions or vocational training establishments, agencies, organizations, or enterprises;

b) Purchase and repair of common medical equipment serving primary healthcare, filing cabinets for managing health records at educational institutions or vocational education facilities, agencies, organizations, and enterprises;

c) Purchase of materials for disease prevention activities, sanitation measures, and medical care activities in the context of primary healthcare.

3. Payment and final settlement of funds:

a) For public educational institutions or vocational education institutions, costs incurred for medical examinations and treatments in the implementation of primary healthcare should be accounted for in the healthcare expenses of the institution and settled with the upper management unit in accordance with current regulations;

b) For educational institutions or private vocational training establishments that record the expenses for medical examinations and treatments within the primary healthcare service into the institution's costs and settle accounts with their superior units (if any);

c) For enterprises and economic organizations, a separate accounting ledger shall be maintained to reflect the receipt and use of funds, which shall not be included in the final settlement of the enterprise's or economic organization's expenses.

d) For other agencies and units that account for expenses related to medical examinations and treatments in primary healthcare, such expenses shall be included in the medical work costs of the agencies and units, and they shall be settled with the relevant upper-level managing authority (if any) or the financial authority at the same level in accordance with current regulations.

4. Educational institutions or vocational education institutions, agencies, organizations, and enterprises that are allocated funds for examination and treatment in primary healthcare as stipulated in this Decree are responsible for utilizing these funds for primary healthcare services, ensuring the availability of medicines and medical equipment for primary healthcare activities. These funds must not be used for other purposes. Any unused allocated funds at the end of the year may be carried over to the next year for continued use. Additionally, they are required to aggregate and report on the management and utilization of these funds in the annual activity report and are not required to settle accounts with the social security authority.

5. The Minister of Health regulates the list of health insurance-covered medical care services, as well as the list of essential medications and medical equipment in primary healthcare that falls within the coverage of the Health Insurance Fund.

Article 64. Management and use of the reserve fund

1. Source of the formation of the contingency fund.

a) The amount allocated annually as stipulated in point a of clause 2 of Article 61 of this Decree;

b) Delayed payments and evasion of health insurance premiums;

c) Interest on late payment, evasion of health insurance contributions;

d) The profit generated from investments in health insurance;

dd) Expenditures that do not comply with regulations must be recovered.

2. The reserve fund shall be used to:

a) Supplement funding for health insurance-covered medical care in cases where the health insurance revenue allocated for medical care according to the provisions of clause 1, Article 61 of this Decree is less than the expenditure on medical care for the year. After the final account settlement assessment, the Vietnam Social Security is responsible for supplementing the entire amount of this differential funding from the reserve fund.

b) Provide advance payments and additional payments for health insurance-covered medical care costs incurred in the previous year as stipulated in point b, clause 4 of Article 65 of this Decree;

c) Reimburse the government budget for the costs of issuing duplicate health insurance cards.

3. In the event that the reserve fund is insufficient to supplement the funds for medical care as stipulated in Clause 2 of this Article, the Vietnam Social Security shall report to the Board of Management of Social Insurance the proposed resolution before reporting to the Ministry of Health and the Ministry of Finance.

The Ministry of Health shall preside over and coordinate with the Ministry of Finance to present measures to the Government to ensure that funds for health insurance-covered medical care are sufficient and timely.

Article 65. Preparation of the revenue and expenditure estimates, notification of the projected expenditures and finalization of the revenue and expenditure of the health insurance fund.

1. Annually, the Vietnam Social Security shall collaborate with the Military Social Security and the People's Public Security Social Security to develop a budget plan for the collection and expenditure of the health insurance fund, which includes: expenditures for health insurance-covered medical care, costs for the organization and operation of health insurance, allocations from the collected revenue for the year to the reserve fund, expenditures from the reserve fund to cover medical care costs of the previous year that have been incurred by health facilities but have not been settled due to any existing issues (if any), as well as investment from temporarily idle funds of the health insurance fund. This plan is submitted to the Social Insurance Management Board for approval and sent to the Ministry of Finance before July 20 of each year. The Ministry of Finance shall lead and coordinate with the Ministry of Health to compile and present to the Prime Minister before November 30 every year the budget estimates for revenue and expenditure of the health insurance fund for the Vietnam Social Security, the Military Social Security, and the People's Public Security Social Security.

2. Provision of estimated expenditure for health insurance-covered medical care and notification of the projected expenditure for health insurance-covered medical care:

a) Within 15 days from the date of receiving the decision on the allocation of the health insurance expenditure and revenue estimates from the Prime Minister, Vietnam Social Security shall allocate the estimated expenditure for health insurance-covered medical care to the social security authority of province or central-affiliated city of not exceeding 92% of the total health insurance revenue estimate nationwide after deducting the amounts allocated by the Prime Minister to the Military Social Security and the People's Public Security Social Security.

b) Based on the provisions of point c of this clause, the health facility shall prepare an estimated expenditure and submit it to the social insurance authority where the health insurance contract is signed. Based on the proposal from the health facility, along with the allocated budget, the provincial social security authority will notify the expected number of health insurance-covered medical care services to the respective health facility. In the case where a health facility anticipates an increase or decrease in expenditures for the year compared to the previously announced amounts, the health facility must submit a written request to the provincial social security authority by October 15 of each year for consolidation and adjustment within the allocated budget of the provincial social security authority.

c) The projected expenditure is determined based on the estimated expenditures for health insurance-covered medical care assigned by the Prime Minister, and the actual expenditures for medical care covered by health insurance in the previous year, anticipated increases or decreases in the occasions of services, the average costs of health insurance-covered medical care at health facilities, the medical care service charges, the scope of health insurance benefits, and any changes in policies and laws related to health insurance.

d) In cases where the total projected expenditures for medical care covered by health insurance of health facilities increase or decrease compared to the estimates provided by the Vietnam Social Security, the provincial or city Social Insurance departments shall compile and send this information to Vietnam Social Security prior to October 30 each year for consideration of adjustments among provinces and central-affiliated cities. The Vietnam Social security authority compiles and reviews the adjustment of the projected expenditure for health insurance-covered medical care among Social security authorities of provinces or central-affiliated cities within the scope of the projected expenditure for medical care, as well as the allocated reserve fund for the previous year, by November 15 of each year to serve as a basis for adjusting the estimated expenditure for health insurance-covered medical care.

3. In cases where the actual expenditure for health insurance-covered medical care of the health facility exceeds the projected amount (including the initial notification at the beginning of the year and the adjustments made during the year), the health facility must review the situation and submit a written explanation detailing the reasons that led to the expenditure exceeding the projected amount to the Social security authority and the Department of Health of the relevant province or central-affiliated city. The social security authority of the province or central-affiliated city is responsible for leading and coordinating with the Health Department as follows:

a) Collaborate with health facilities to review the causes affecting the exceedance of the projected expenditures for medical care funded by health insurance according to the explanations provided by these facilities; assess the expenses that are higher than the average increase of similar health facilities of the same professional classification, whether general or specialized health facilities, within the province, central-affiliated city, or nationwide.

b) Review and unify the determination of medical care costs covered by health insurance that exceed the planned expenditure to comply with legal regulations on medical care and health insurance for reimbursement and to supplement funding for health facilities; deny reimbursement for medical care costs identified through review as non-compliant with legal regulations on medical care and health insurance.

In the event of a disagreement regarding the refusal to cover medical care costs, the health facility has the right to propose to the social security authority of the province or central-affiliated city, the Department of Health for consideration, or to compile and send to the Ministry of Health for resolution in accordance with the law;

c) In cases where the budget allocated by the Vietnam Social Security is insufficient to supplement funding for health facilities, the Social security authorities of provinces and central-affiliated cities shall send a request to the Vietnam Social Security to supplement the funding for health insurance medical care within the scope of the health insurance-covered medical care cost estimates by the Prime Minister.

4. In the case where the total actual expenditure for health insurance-covered medical care in the year exceeds the estimated expenditure allocated by the Prime Minister, the Vietnam Social Security shall implement the following:

a) In the case where the amount allocated from the contingency fund according to the budget revenue assigned by the Prime Minister is sufficient to cover additional expenses for health insurance-covered medical care that exceed the budget estimates, the Vietnam Social Security will supplement the funds for health insurance-covered medical care from the contingency fund to cover these costs and report to the Board of Directors of the Social security authority, the Ministry of Health, and the Ministry of Finance on the results of the implementation;

b) In the event that the reserve fund allocation from the revenue for the year as estimated by the Prime Minister is insufficient to cover the additional expenses for health insurance-covered medical care beyond the budget, the Vietnam Social Security shall report to the Social Insurance Management Council for approval before sending it to the Ministry of Finance to lead and coordinate with the Ministry of Health to submit to the Prime Minister for consideration, in order to supplement the funds for health insurance-covered medical care beyond the budget from the reserve fund (if available), which will be reconciled in the financial year in which the payments are made.

During the waiting period for the Prime Minister's approval, the social security authority shall advance the costs of medical care covered by health insurance, as approved by the Social Insurance Management Council.

After receiving approval from the Prime Minister, the social security authority provided the remaining funding for health facilities;

c) In the event that the reserve fund is insufficient to supplement the funding for health examinations and treatment covered by health insurance, the Vietnam Social Security shall summarize and report to the Management Board through a plan to ensure financial resources for health examinations and treatments covered by health insurance before submitting to the Ministry of Health to collaborate with the Ministry of Finance in reporting to the competent authority for decision-making as stipulated in Clause 3, Article 64 of this Decree.

5. Advance payments, payments, and settlement of medical care costs covered by health insurance for the health facility shall be conducted quarterly in accordance with the provisions of clauses 1 and 2 of Article 32 of the Law on Health Insurance.

In cases where the medical care costs proposed for payment are subject to obstacles, the time for resolving the issues and making payments shall not exceed 12 months from the date the health facility submits the payment request.

6. Every year, prior to October 1st, the Vietnam Social Security is responsible for compiling and preparing the financial settlement report for the previous year's health insurance fund in accordance with the provisions of Article 32 of the Law on Health Insurance.

7. The contents regarding the financial mechanism of the health insurance fund not specified in this Decree shall be implemented in accordance with the Government's regulations on the financial mechanisms of the social insurance, health insurance, and unemployment insurance funds.

Chapter XI

APPLICATION OF INFORMATION TECHNOLOGY AND DIGITAL TRANSFORMATION IN IMPLEMENTING HEALTH INSURANCE

Article 66. Principles of applying information technology and digital transformation in the implementation of health insurance

1. Comply with the legal regulations on the application of information technology; legal regulations on health insurance-covered medical care; laws on the protection of state secrets and related confidentiality; legal regulations on electronic transactions, storage, and information security.

2. Adhere to the technical standards and regulations, ensuring compatibility, smoothness, and safety, facilitating the electronic transactions between health facilities and the social security authority.

3. Ensure the security and privacy of the data and information related to the medical care of individuals participating in health insurance.

4. Ensure the technical infrastructure, transmission lines, software, and human resources meet the requirements for the application of information technology and digital transformation in the implementation of health insurance.

5. Ensure the capacity for integrated connectivity and data sharing regarding health insurance with other information technology systems.

Article 67. Content of the application of information technology and digital transformation in the implementation of health insurance

1. The application of information technology to support the state management of health insurance at the central and local levels.

2. Utilize information technology to digitize the information of health insurance participants.

3. Utilizing information technology to develop and establish payment methods for outpatient and medical treatment expenses under health insurance.

4. The application of information technology in the service of medical care under the health insurance system at health facilities.

5. The application of information technology to serve the processes of advance payment, assessment, payment, and final settlement of health insurance-covered medical care costs between the social security authority and health facilities.

6. The application of information technology serves the management and allocation of health insurance funds, as well as the collection and expenditure of health insurance.

7. The application of information technology in the implementation of health insurance to serve other tasks directed by the Government.

Article 68. Responsibilities of agencies and units regarding the application of information technology and digital transformation in the implementation of health insurance

1. Responsibilities of the Ministry of Health:

Establish, regulate, and issue common code sets applicable in the health insurance examination and treatment; data standards, formats, connections, interoperability, and electronic data transfer in the health insurance examination and treatment, evaluation, and payment of medical care costs.

2. Responsibilities of the Ministry of Finance:

Direct and organize the implementation of information technology application and digital transformation in the management and execution of the laws, policies related to health insurance, as well as the management and utilization of the health insurance fund.

3. The Ministry of Public Security is responsible for ensuring connectivity and interoperability between the National Database on Health Insurance and the National Database on Population, as well as developing features on the National Electronic Identification Application (VNeID) to serve the public and relevant agencies in addressing legal policies and regulations regarding health insurance.

4. The responsibilities of the Vietnam Social Security under the Ministry of Finance:

a) Apply information technology and digital transformation to facilitate and serve citizens, agencies, and organizations in the implementation of the laws and policies regarding health insurance;

b) Establish and implement a monitoring and warning system in the enforcement of regulations and policies regarding health insurance.

c) Organize the collection and payment of health insurance online, automatically integrate notifications for health insurance participants regarding the deadline for payment and the premium rates for the next payment 10 days before the health insurance card expires, automatically renew the health insurance policy when the participant has made the payment for health insurance and notify the result of the payment;

d) Implement assessment, sign provider contracts with health facilities by the electronic means.

dd) Ensure that the data reception gateway operates effectively;

e) Share full, accurate, and timely data from the national database on insurance with the Ministry of Health to carry out the state management functions regarding health insurance.

5. Responsibilities of health facilities:

a) Implement the application of information technology and digital transformation in the examination and treatment of patients covered by health insurance in accordance with legal regulations;

b) Ensure the maintenance of standards for connectivity and interoperability of health insurance-covered medical care data that have been validated with the information system and health insurance assessment of the social security authority in accordance with regulations during the execution of the provider contract.

c) Be legally responsible for the accuracy and legality of the data; ensure the safety and confidentiality of information in accordance with legal regulations.

Chapter XII

IMPLEMENTATION CLAUSES

Article 69. Grandfather clause

1. In cases where patients visit health facilities before the effective date of this Decree and complete their medical care process from the effective date of this Decree, the provisions of this Decree or the regulations prior to the effective date of this Decree shall apply, in a manner that is favorable to patients regarding health insurance procedures and entitlements.

2. In the case where a participant in health insurance has been determined by a competent authority to belong to the group participating in health insurance funded or supported by the state budget prior to the enforcement of this Decree and undergoes a change in status due to the merging of administrative units while restructuring the organization of the political system, the health insurance participant shall continue to have their health insurance premiums fully or partially subsidized by the state and shall enjoy the benefits according to the category affirmed in the document from the competent authority until the expiration of the validity of that document or until a new category is reaffirmed through a new document.

3. In the case of health insurance contracts for examination and treatment signed before July 1, 2025, which remain valid after July 1, 2025, they shall be performed until the expiration of the signed contract, except for the cases stipulated in Clause 8 of this Article.

4. In the case of private health facilities that have signed contracts for the supply of drugs, chemicals, testing supplies, and medical equipment before July 1, 2025, in accordance with the law on bidding, they are permitted to use and fully settle the quantity of drugs, chemicals, testing supplies, and medical equipment as per the signed contract.

5. The entities participating in health insurance as stipulated in points e, h, i, k, o, r, s, and t of clause 3, and points a, b, d, and g of clause 4 of Article 12 of the Law on Health Insurance, along with the documents related to the establishment of the list of entities participating in health insurance, which are currently being handled by district-level authorities, shall be transferred to the communal People's Committee for continued implementation in accordance with the legal documents issued prior to the effective date of this Decree until new documents are issued.

6. The health centers of districts, towns, cities under provincial jurisdiction, and central-affiliated cities when reorganized under a new designation will continue to be subject to the provisions stated in point c of clause 1 of Article 22 of the Law on Health Insurance regarding the health insurance-covered medical care.

7. The phrase “island district” in point b, clause 4 of Article 22 of the Law on Health Insurance shall be replaced with the phrase “special zone”.

8. In cases where health facilities reorganize, merge, or change their names when implementing the restructuring of the local government apparatus at two levels:

a) Health facilities will continue to apply the health insurance-covered medical care service charges that have been stipulated, approved, and reimbursed by the competent authorities before the facilities are rearranged, reorganized, merged, or renamed for the reimbursement of health insurance-covered medical care costs, until new prices are stipulated and approved by the competent authorities for the new facilities.

b) In cases where a health facility must apply for a new operational license, renewal or modification of their operational license, during the process of obtaining the new, renewed, or modified operational license as prescribed, the operational license previously issued to the health facility before the reorganization, restructuring, merging, or renaming shall continue to be valid for both the old and new facilities for the purpose of providing medical care, and maintaining the validity of provider contracts that have been signed, until new provider contracts are signed for the new facility according to the new operational license. The health facility is responsible for ensuring the quality of medical care services.

c) Registration for receiving medical care at primary care providers of participants and the number of health insurance cards allocated to facilities for initial medical care before the date of reorganization, consolidation, renaming, will continue to be used for the new facility until further guidance is provided by the Department of Health;

d) The code of the health facility, the seal of the health facility, and the seal of the facility that signed the provider contract prior to the organization, consolidation, or name change can continue to be used until the new facility is granted a new code and a new seal; In the event that the health facility has had its old seal revoked but has not been issued a new seal, it is permitted to finalize procedures after obtaining the new seal.

dd) Health insurance cards and any information on health insurance cards that are subject to changes due to rearrangements, reorganizations, mergers, or name changes shall continue to be used until they are adjusted by the competent authority.

e) Based on the local practice requirements, the People's Committee of the province or central-affiliated city shall decide solutions to address arising situations in order to ensure the stable operation of health facilities during the transitional phase when reorganizing, merging, or changing the names of health facilities; assign a responsible unit to represent and address arising issues related to the implementation of contracts, payments, and final settlements for health insurance-covered medical care costs, patient transfers between health insurance-covered health facilities, procurement, ensuring the supply of medicines and medical equipment, and resolving any arising complications related to the transition process until the health facilities are granted new operation licenses and sign new provider contracts.

9. The implementation of electronic data verification for health insurance-covere medical care costs covered by health insurance must be completed by January 1, 2026, at the latest.

Article 70. Entry into force

1. This Decree shall take effect from August 15, 2025, except for the provisions in Clause 2 and Clause 3 of this Article.

2. The provisions from Article 1 to Article 11, Articles 14, 15, 17, 18, 19, from Article 22 to Article 36, from Article 39 to Article 44, Articles 49 and 50, from Article 54 to Article 61, as well as Articles 69, 70, 71, and 72 of this Decree shall come into effect on July 1, 2025.

3. Clause 8 of Article 69 of this Decree shall take effect from July 1, 2025, until December 31, 2025.

4. Abolish the provisions of the following documents effective from July 1, 2025:

a) The provisions from Articles 1 to 12, Clauses 1, 2, 3, 4, 5, and 6 of Article 14, from Article 16 to Article 26, Clauses 1, 2, 3, 4, 5, 6, 8, 9, and 11 of Article 27, from Article 28 to Article 36, and all forms in the Appendix issued together with Decree No. 146/2018/ND-CP dated October 17, 2018, of the Government detailing and guiding the implementation of certain provisions of the Law on Health Insurance amended and supplemented by Decree No. 75/2023/ND-CP dated October 19, 2023, and Decree No. 02/2025/ND-CP dated January 1, 2025 of the Government;

b) Clauses 3 and 4 of Article 95 of Decree No. 24/2024/ND-CP dated February 27, 2024, of the Government stipulates in detail some provisions and measures for the implementation of the Law on Bidding regarding the selection of contractors;

c) Clause 5 of Article 4 of Decree No. 74/2025/ND-CP dated March 31, 2025, of the Government amending and supplementing several provisions of Decree No. 70/2015/ND-CP dated September 1, 2015, of the Government detailing and guiding the implementation of certain articles of the Law on Health Insurance for the People's Army, People's Police, and personnel involved in cryptographic tasks.

5. The following documents shall be abolished effective from August 15, 2025:

a) Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government detailing and guiding the implementation of certain provisions of the Law on Health Insurance;

b) Decree No. 75/2023/ND-CP dated October 19, 2023 of the Government amending and supplementing certain Article of Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government detailing and guiding the implementation of certain articles of the Law on Health Insurance;

c) Decree No. 02/2025/ND-CP dated January 1, 2025, of the Government amending and supplementing certain provisions of Decree No. 146/2018/ND-CP dated October 17, 2018 of the Government which stipulates in detail and guides the implementation of certain provisions of the Law on Health Insurance that has been amended and supplemented by Decree No. 75/2023/ND-CP dated October 19, 2023 of the Government.

6. In the event that the referenced documents in this Decree are replaced or amended, the provisions of the replacing document or the amended document shall apply.

Article 71. Organization of implementation

1. The Ministry of Health shall:

a) Provide guidelines for the organization of the implementation of policies and laws on health insurance;

b) Provide guidelines for compiling a list of entities under its management; the identification and compilation of a list of entities specified in Points h, r, s, and t of Clause 3, Article 12 of the Law on Health Insurance.

c) Provide guidelines for health facilities to enhance the application of information technology in health insurance-covered medical care; to sign, authenticate, and transfer data on requests for payment of health insurance-covered medical care costs to the health insurance-covered medical care data reception system of the Ministry of Health and the assessment information system of the Vietnam Social Security for the purpose of managing health insurance and assessing and settling health insurance-covered medical care costs.

d) Direct the health facilities and the centralized procurement units to strictly implement the regulations related to procurement and bidding to ensure the timely provision of medicines, chemicals, and medical equipment covered for health insurance participants, practice of thrift and prevention of waste.

dd) Direct health facilities to comply with legal regulations regarding medical care, the professional guidelines of the Ministry of Health; and the legal provisions related to the provision of medical technical services ensuring quality, efficiency, and cost-effectiveness.

e) Take charge and cooperate with the Ministry of Finance in preparing and submitting the Government's reports to the National Assembly on the implementation of health insurance regimes and policies, including the management and use of the health insurance fund on an emergency, periodic, or annual basis.

g) Take charge and cooperate with relevant agencies in inspecting the implementation of policies and laws on health insurance;

h) Issue guidelines for estimating expenditures, adjusting the estimated expenditures for health insurance-covered medical care, and determining the amount of health insurance-covered medical care expenditures that exceed the planned budget reimbursed by the health insurance fund.

2. The Ministry of Finance shall:

a) Balance and allocate the central budget to support local areas that are not yet able to balance their budgets in order to ensure the funding for the implementation of health insurance policies in accordance with the provisions of the law on the state budget.

b) Direct and guide the organization in the implementation of policies and laws on health insurance, and manage and use the Health insurance fund under its management;

c) Provide regulations on the authority to sign provider contracts of the social security authorities in accordance with the functions, duties, powers, and organizational structure of the Vietnam Social Security;

d) Issue consolidated forms of payment and settlement of health insurance-covered medical care costs, provide specific regulations on procedures for evaluation of health insurance-covered medical care costs;

dd) Prepare annual reports on the management and use of the health insurance fund and submit them to the Ministry of Health for compilation in accordance with regulations.

3. The Ministry of Defense, the Ministry of Public Security, and the Government Cipher Committee are responsible for guiding the implementation of health insurance for entities under the management of the Ministry of Defense and the Ministry of Public Security seeking medical care in accordance with the provisions of this Decree; guiding the identification of the entities who are relatives of those performing other tasks within cipher organizations stipulated in Clause 5, Article 5 of this Decree.

4. The Ministry of Home Affairs shall:

a) Provide guidance on the identification and listing of entities managed by the Ministry of Home Affairs stipulated in points e, i, k, and individuals residing in island communes and special zones specified in point o of clause 3, Article 12 of the Law on Health Insurance;

b) Examine the implementation of legal provisions regarding the responsibility for participation in health insurance of employers and employees stipulated in Clause 1, Article 12 of the Law on Health Insurance, and the entities specified in point a of this clause, excluding entities managed by the Ministry of National Defense and the Ministry of Public Security.

5. The Ministry of Education and Training is responsible for guiding the identification and compilation of the list of entities specified in point b, clause 4, Article 12 of the Law on Health Insurance.

6. The Ministry of Culture, Sports and Tourism is responsible for identifying and guiding the preparation of a list of entities specified in Point h, Clause 4, Article 12 of the Law on Health Insurance and Clause 3, Article 5 of this Decree.

7. The Ministry of Agriculture and Environment shall:

a) Research and develop criteria for identifying poor households; near-poor households; households engaged in agriculture, forestry, fisheries, and salt production with average living standards appropriate to the socio-economic situation of each period, and submit them to the Prime Minister for promulgation;

b) Provide guidelines for identifying and listing entities managed by the Ministry of Agriculture and Environment for those belonging to poor households; ethnic minorities from near-poor households residing in communes and hamlets in ethnic minorities and mountainous areas; individuals residing in extremely disadvantaged areas specified in Point o of Clause 3 and Points a and d of Clause 4 of Article 12 of the Law on Health Insurance.

8. The Department of Ethnic Affairs and Religions is responsible for guiding the identification and listing of ethnic minority individuals residing in disadvantaged areas stipulated in point o of clause 3 and point g of clause 4 of Article 12 of the Law on Health Insurance.

9. Vietnam Social Security under the Ministry of Finance shall:

a) Direct the social security authorities at all levels to sign contracts with health facilities that meet the conditions stipulated in this Decree; provide forms and guidance to the People's Committees of communes in compiling and managing the lists of participants in health insurance under their jurisdiction;

b) Direct the social security authorities of provinces or central-affiliated cities to actively coordinate with the Departments of Health, Departments of Finance, and health insurance-covered medical care facilities in the provinces or central-affiliated cities, bordering provinces or central-affiliated cities, and relevant agencies to resolve issues within their jurisdiction or petition competent authorities to promptly consider and address any issues arising in the implementation of health insurance policies and laws.

c) Perfect the information technology system to meet the requirements for timely, seamless, and comprehensive reception, assessment, and feedback to health facilities regarding the data on requests for payment of health insurance-covered medical care costs; ensuring the accuracy, safety, and confidentiality of information and the rights of involved parties;

d) Ensure the effectiveness of the inspection and the capability of the team engaged in health insurance inspection; proactively review, detect, and promptly send warning information to health insurance-covered medical care facilities regarding health insurance-covered medical care costs that are significantly higher than the average cost of facilities with the same professional classification, whether general or specialized health facilities, to enable these facilities to check and review in accordance with legal regulations in order to use the health insurance fund rationally and effectively.

dd) Timely compile information on the total copayment amount accrued in the financial year for patients, the time when patients have participated in health insurance for at least 05 continuous years, and notification on the data reception portal for health facilities to look up and determine the time when patients are eligible for copayment exemption during their occasion of service; ensuring that it does not affect the rights of patients.

e) Provide consolidated reports and period reports, annually, or provide ad-hoc reports as required by state management agencies regarding the implementation of health insurance regimes and policies; the situation of revenue, expenditure, management, and use of the health insurance fund, and send them to the Ministry of Health and the Ministry of Finance for compilation as prescribed;

g) Share and transfer comprehensive and timely data on health insurance-covered medical care costs to the Ministry of Health in order to develop and implement payment methods and formulate policies in accordance with legal regulations.

h) Provide the Departments of Health of provinces or central-affiliated cities with the number and structure of participants in group health insurance registered for receiving medical care at primary care providers and any changes in information within the first 15 days of each quarter (if applicable), using Form No. 12 in the Appendix enclosed herewith.

i) Publicly disclose and promptly update the requirements and guidelines regarding the reception and reporting of incidents and difficulties related to the acceptance of data, rejection of data on health insurance-covered medical care costs on the data reception portal before applying it in health insurance assessment.

10. The People's Committees of provinces or central-affiliated cities shall:

a) Direct and organize implementation of policies and laws on health insurance in their areas;

b) Propose to the People's Councils of the same level to ensure funds for payment of health insurance for individuals whose health insurance premiums are fully or partially subsidized by the state in accordance with applicable regulations;

c) Direct, urge, and ensure the implementation of conditions for the application of information technology, digital transformation, and data interoperability in health insurance-covered medical care by health facilities under their management in accordance with regulations;

d) Direct and take the lead in resolving the difficulties encountered during the implementation of health insurance policies and laws between health facilities and the social security authorities within their areas of management.

dd) Organize the proper implementation of the systematic planning of health facilities; direct and inspect the compliance with the operational conditions of health insurance-covered medical care facilities; assess the health insurance-covered medical care needs of the people and the capacity of the system of health facilities in their areas, and implement solutions to ensure a balance and suitability between the number of health insurance-covered medical care facilities and the health care needs of the people in their areas.

e) Based on the local budget capacity and other lawful funding sources, the People's Councils of provinces or central-affiliated cities shall decide the rates of subsidization for entities exceeding the minimum rates of subsidization stipulated in points b, c, d, dd, and e of clause 6, Article 6 of this Decree; the rates of subsidization for entities not eligible for the rates of subsidization stipulated in points b, c, d, dd, and e of clause 6, Article 6 of this Decree; the beneficiaries of the support and rates of subsidization for co-payment of health insurance-covered medical care costs for participants in health insurance when seeking medical care.

Article 72. Responsibility for implementation

Ministers, Heads of ministerial agencies, Heads of Governmental agencies, the Chairpersons of the People’s Committees of provinces and central-affiliated cities and relevant entities are responsible for implementation of this Decree.