全民健康保險醫事服務機構特約及管理辦法

1The medical care institution or the responsible medical personnel applying to be a contractor will be disqualified should any of the following circumstances occur:

21. Violation of medical care laws, currently under disciplinary suspension, or having unpaid fines;

32. Violations of the laws and regulations governing National Health Insurance (hereinafter referred to as the “Insurance”) and as a result, contract suspended or terminated, or fines not paid up in full;

43. Pending issues with the Insurer and refusal to cooperate to seek resolutions;

54. Outstanding debts to the Insurer and refusal to allow the Insurer to deduct such outstanding payments from payable medical costs and expenses;

65. Responsible medical personnel unable to practice due to illness as diagnosed by professional physician(s) and deemed by the Insurer on the basis of on-site investigations;

76. Failure to renew expired licenses held by responsible medical personnel;

87. Retention of responsible medical personnel(s) or medical personnel who have been subject to disciplinary action for violations but have not yet completed the enforcement.

1The medical care institution or the responsible medical personnel applying to be a contractor will be disqualified in five years should any of the following circumstances occur:

21. The institution at the same address sees its franchise contract suspended or terminated twice or more within the last five years;

32. The franchise contract is suspended or terminated again within five years after the completion of the previous franchise contract termination;

43. The franchise contract is terminated or will be terminated for the second time within five years after the completion of the previous contract termination.

5No contract shall be granted to any applicant should any of the above situations repeat within five years of being given the contract.

6It is possible to suspend the contract to specific service items or categories of a medical care institution if the Insurer deems such service items or categories to violate the Insurance’s provisions based on on-site investigations or if there are factual violations of the Insurance’s provisions and the situation of violation or related facts sustained.

7No contract shall be granted within five years after the five suspensions or terminations of specific service items or categories or three suspensions or terminations of the same service item or category within five years in pursuant to the situations described in each Subparagraph of Paragraph 1.

The Insurer shall not pay for any expenses associated with the contracted medical care institution services rendered to the insurance beneficiaries by any medical personnel liable for the actions described in Subparagraphs 2 to 3 of Paragraph 1 of the preceding article.

1The Insurer shall conclude franchise contracts with contracted medical care institutions that have passed the review of their application for contracting according to the principles set out in Article 2.

2The abovementioned contracts shall be in standard form, and their contents shall be reviewed once every year. Any amendment shall be applicable to the following contractual renewals.

3Where the circumstances set forth in Articles 38, 39, 40, or 47 are not applicable to medical personnel or practicing physicians, pharmacists (assistant pharmacists), physical therapists (physical therapy technicians), occupational therapists (assistant occupational therapists), medical technologists (medical technicians) and medical radiation technologists (medical radiological technicians) of a medical care institution within five years from the application date for contracting, the effective date of contracting may be fixed retrospectively to the date of the practicing license issued for the medical care institution if the application date is within fifteen working days from the issuance of the said practicing license. 3

1The abovementioned contract is valid for three years. Upon expiry of the franchise contract and in the absence of written notices from the contracted medical care institution to the Insurer to request the termination of its contracted status, the Insurer may renew the contract pursuant to the Regulations if the contracted medical care institution meets any of the following criteria:

21. Not in the circumstances described by the Regulations where no contract shall be granted;

32. No received any disciplinary sanctions (contract-violation point) or improvements already made if having been subject to any contract-violation point;

43. Contract suspended, but improvements already made after suspension;

54. Fines imposed in accordance with the Act are paid up in full;

65. Not in the circumstances described by Articles 4, 5 and 45.

1Hospitals applying for the contracting for hospital stays shall be reviewed by hospitals. Mental state restoration medical care institutions applying for the contracting of community rehabilitation services for the mentally ill shall be evaluated and approved by medical care institutions.

2The Insurer shall refer to the changed results of assessments on hospitals after the expiry of the previously assessed results in the review of the Insurance payment levels. For any hospitals not accepting further assessments or failing to pass assessments, the contract shall be changed to the elementary medical care units.

3The Insurer may refer to the Hospital Accreditation Standards to determine the contract categories for new hospitals that have not yet been evaluated by the central competent authority of health on the basis of special cases pursuant to relevant laws and regulations.

4Contracted medical care institutions other than hospitals shall participate in assessments or investigations organized by the central competent authority of health pursuant to relevant laws and regulations. The contract shall be terminated if the assessment results fail or the contracted medical care institution refuses to participate in the assessment.

1Contracted medical care institutions shall display the designated mark of contracted medical service institutions in a conspicuous location.

2Upon suspension or termination of the contract, contracted medical care institutions shall remove the abovementioned designated mark. However, if the suspension or termination is applicable to specific service items or categories, contracted medical care institutions shall post the notices for the periods and service items or categories suspended or terminated at registration desks (and on the websites) and other conspicuous locations.

Contracted medical care institutions shall issue receipts in compliance with the requirements set forth by the Enforcement Rules of Medical Care Act for the medical services rendered to the insurance beneficiaries. The receipts shall list the serial numbers of the National Health Insurance Card of the insurance beneficiaries for the medical service provided.

In the event that a beneficiary fails to provide the National Health Insurance Card or identification document in a timely manner for any reason, the contracted medical care institution shall not only provide medical service but also retain the payment and refund records.

For the items covered by the Insurance, medical service institutions shall not require beneficiaries to pay additional fees, purchase medications or treatment materials, or undergo self-paid examinations except for collecting fees as stipulated in Article 14. They also shall not provide or claim fees for services requested by beneficiaries that are not medically necessary.

1In the event that the contracted medical care institution provides a beneficiary with a medical device of difference payment, it shall request the beneficiary for payment in compliance with the following:

21. The payment standard shall be submitted to and approved by the local competent health authority;

32. The item, fee, product features, as well as side effects of the medical device, such as difference payment and curative effects compared to the medical devices reimbursed by the Insurance, shall be publicized on the website or a place easily seen in the institution.

43. Except in the case of an emergency, the relevant manual should be delivered to the patient or the patient’s family two days prior to the operation or treatment. In addition, the institution shall give detailed explanations to the patient or the patient’s family, who should then fill out two counterparts of the consent form to the difference payment in person, with one copy held by the patient and the other kept with the patient’s medical records; and

5The manual set forth in the preceding subparagraph shall clearly stipulate the fee, product features, reasons for use, warnings, as well as side effects of the medical device of difference payment and its curative effects compared to the medical devices reimbursed by the Insurance. The consent form shall clearly state the item name, item code, price listed by the institution, quantity, and difference.

Unless in an emergency or due to unexpected surgeries, examinations, or treatments, contracted medical care institutions may not suggest or request patients or their relatives to use the service items not covered by the Insurance when rendering operations, medical checks, or procedures to insurance beneficiaries.

All entries in account books and records related to the contracted medical care services provided by a contracted medical care institution shall be consistent with the costs and expenses thereof declared to the Insurer. It shall be placed under custody for five years.

If the responsible medical personnel(s) of contracted medical care institutions have become incapable of performing duties for more than thirty days, he/she/they shall report such event to the competent authority that issues their practicing licenses according to relevant laws and regulations. Meanwhile, he/she/they shall report to the Insurer within ten days after the aforesaid thirty days. This clause shall also be complied with upon a change of any matter previously reported to and recorded with relevant competent authorities.

In case of name changes of contracted medical care institutions or changes of the responsible physicians of public medical care institutions, the medical care institutions of medical-legal persons or medical care institutions of legal persons shall report such changes to the Insurer by submitting the practicing licenses issued by the competent authority.

The Insurer may conduct on-site investigations of contracted medical care institutions when necessary.

When applying for Insurance payments for labor, clinics shall obtain approvals from the local competent authority for the establishment of operation rooms, labor rooms, infant rooms, and observation wards. The Insurance shall not cover Cesarean sections in the absence of operation rooms.

1Upon the approval from the local competent authority and the consent from the Insurer, contracted medical care institutions may appoint physicians or necessary medical personnel to provide ambulatory medical care services and health rehabilitation diagnoses and treatments in registered old-age care and nursing centers, care institutions or welfare institutions for the mentally and physically challenged and nursing homes (hereinafter collectively referred to as “nursing institutions”) when the following conditions are met:

21. The contracted medical care institutions that provide ambulatory medical care services shall be contracted hospitals and clinics. The service institutions that provide health rehabilitation diagnoses and treatments shall be contracted hospitals and health rehabilitation clinics;

32. When providing health rehabilitation therapies and services, in accordance with the service categories, it is necessary to appoint physicians, physical therapists, occupational therapists, and speech or hearing therapists who meet the requirements set forth in the Fee Schedule and Reference List for Medical Services;

43. Nursing institutions shall be equipped with the diagnosis and treatment facilities as described by the Standards of the Facilities of Medical Treatment Establishments. When offering health rehabilitation treatments and services, it is necessary to be equipped with the facilities required for physical therapies, occupational therapies, and speech or hearing therapies according to the services rendered;

54. It is necessary to file a list of insurance beneficiaries that nursing institutions service to the Insurer. This list shall be renewed once every month.

6The Insurer may reject the application from the contracted medical care institution for support services if the aforesaid institution is found to be violating the regulations.

1The services rendered by the physicians and necessary medical personnel by the contracted medical care institutions specified in the preceding article shall be provided only in the following timeslots:

21. Ambulatory medical care services and health rehabilitation diagnoses and treatments provided by the physicians of contracted medical care institutions shall be limited to a total of three timeslots each week. Health rehabilitation therapy treatments and services provided by therapists shall be limited to a total of three timeslots each week;

32. Ambulatory medical care services and health rehabilitation diagnoses and treatments provided by the physicians of the contracted medical care institutions offering accommodations to up to 300 mentally or physically challenged patients are limited to a total of six timeslots per week. Health rehabilitation therapy treatments and services provided by therapists shall be limited to a total of six timeslots each week;

43. When the contracted medical care institutions are approved to provide ambulatory medical care services and rehabilitation diagnoses and services in the nursing institutions, other contracted medical care institutions may not apply for the contracting of such services to be rendered to the same nursing institutions. Notwithstanding, the contracted medical care institution that has insufficient medical departments may request other contracted medical care institutions to form a team in order to offer integrated medical services in nursing institutions. The major contracted medical care institution should be responsible for filing expenses and managing medical records.

5In the case of the circumstances set forth in the preceding paragraph, there shall only be one physician and one rehabilitation therapist in any given period. Notwithstanding, in the case of nursing institutions that provide early treatment, there shall be no more than three rehabilitation therapists who provide treatment services in any given period.

Prescriptions from and artificial limbs installed by physicians working for contracted hospitals in health rehabilitation, orthopedics, or cosmetic surgery, as well as physical therapists and occupational therapists, in compliance with the Pharmaceutical Affairs Act, may be covered by the Insurance. However, the coverage granted before the amendment on September 15, 2010, may be applicable to the regulations before the amendment.

1Unless in compliance with laws and regulations and with prior reporting to the Insurer and consent from the Insurer, the medical services rendered outside the premise of contracted medical care institutions by physicians of the service institutions are not covered by the Insurance.

2With consent from the Insurer, contracted medical care institutions may dispatch their medical personnel to off-islands and mountains to provide medical services to insurance beneficiaries via medical care tour programs.

Contracted medical care institutions may not refuse to provide medical services to insurance beneficiaries without any legitimate causes, nor can they demand earnest money from insurance beneficiaries.

1The transfers and referrals of insurance beneficiaries by contracted medical care institutions shall be based on medical requirements.

2Contracted medical care institutions shall administer appropriate procedures and provide proper assistance to insurance beneficiaries when their conditions are stabilized. They are discharged from the hospital or transferred to chronic care wards.

1Contracted hospitals or clinics may delegate contracted medical examination clinics or medical radiological institutions to perform tests, inspections, and examinations.

2Contracted physical therapy clinics or occupational therapy shall provide medical services in accordance with the Physical Therapists Act or Occupational Therapists Act. Such medical services shall be based on the prescriptions by physicians of contracted hospitals or clinics in the health rehabilitation department, neurology department, orthopedics department, neurosurgery department, plastic surgery department, or general medicine department.

3The physicians in general medicine mentioned above shall be recognized by the Insurer as having a specialty in rheumatism.

4Occupational therapies in Paragraph 2 may also be based on the prescriptions of psychiatrists.

Home nursing care provided by the nursing homes with practicing licenses for home nursing care to insurance beneficiaries living in the accommodation of the nursing homes may be covered by the Insurance.

Acute care wards mentioned in Article 47 refer to the wards with sickbeds for patients suffering from acute diseases, quarantine diseases, special diseases, and psychiatric acute diseases.

Chronic care wards mentioned in Article 47 refer to the wards for patients suffering from chronic diseases (including chronic tuberculosis and Hansen’s disease) or chronic psychiatric diseases.

Contracted hospitals shall register their wards at the local competent authority of health and report such details to the Insurer for recordation purposes.

1Insurance wards mentioned in Paragraph 1 of Article 67 refer to the wards for the patients not charged for the difference in ward fees in contracted hospitals.

2Contracted medical care institutions may not charge insurance beneficiaries the difference in ward fees except for the following wards:

31. An acute care ward with two sick beds or less.

42. A chronic care ward with two sick beds or less.

1The number of insurance wards sickbeds shall account for at least 75% of the total amount of sickbeds for the contracted medical centers of public hospitals, regional hospitals and local hospitals. The number of insurance wards sickbeds shall account for at least 60% for non-public hospitals.

2The above ratios shall be calculated separately for acute care wards and chronic care wards. Failure to meet the requirements for facilities shall be rectified within six months by submitting a proposal to the Insurer.

Contracted hospitals shall clearly display, at the inpatient registration desks and on the websites, the total number of sickbeds, the number of occupied and available sickbeds for different types of wards, the number and percentage of sickbeds in insurance wards, the number of sickbeds in the wards for which price differences are charged and the total difference charged. Such data shall also be displayed at ward nursing stations in conspicuous locations.

1The Insurer shall inform contracted medical care institutions to make improvements for any of the following circumstances:

21. Failure to register the National Health Insurance Card and upload medical data of insurance beneficiaries in accordance with the regulations;

32. Failure to assist the Insurer in applying for coverage by labor insurance for occupational diseases and accidents and the subrogation right under the compulsory automobile liability system by issuing the necessary receipts or assisting in filing;

43. Non-purposeful errors in data filed for the survey of medicine prices;

54. Other non-major breach of the terms and conditions of the franchise contract.

1The Insurer may impose one contract-violation point to the contracted medical care institutions for any of the following circumstances:

21. Patient transfer not conducted in accordance with medical laws or laws and regulations in relation to the Insurance;

32. Violation of Articles 10 to 14, Articles 16 to 17, Article 25, Paragraph 2 of Article 32, Article 33 or Article 34;

43. Failure to audit the medical papers of insurance beneficiaries in accordance with the Regulations Governing the National Health Insurance Medical Care. Notwithstanding, the above may not apply to the case where the National Health Insurance Card is later submitted for inspection after emergency treatment is given;

54. Failure to return the Insurance medical expenses after deducting the co-payments made by the beneficiary pursuant to the Regulations;

65. Failure to charge insurance beneficiaries the fees they shall pay at their own expense or declare medical expenses, as stipulated by the Regulations;

76. Improper solicitation of patents for accepting medical services covered by the Insurance and such behavior penalized by the health competent authority;

87. Improper request for difference payment from a beneficiary with the difference exceeding the maximum benefit set by the Insurer;

98. In violation of Article 73 of the Act; or

109. Failure to rectify the situation within the deadline set forth by the Insurer.

1The Insurer may deduct ten times the reported medical expenses by the contracted medical care institutions based on the average total value of the most recent quarter of their locations should the contracted medical care institutions be found under any of the following circumstances:

21. Failure to provide medical services according to prescription slips, medical records, or other records;

32. Provision of medical services without diagnoses from physicians;

43. Prescription slips or medical expenses reported not recorded in medical history or records;

54. Failure to produce medical history or records to facilitate the reporting of medical expenses;

65. Declaration of medical expenses knowing that patients use the National Health Insurance Card of others;

76. Retention of personnel who are not qualified medical personnel to conduct medical personnel duties other than those of physicians;

8The Insurer may directly deduct the medical expenses payable to the contracted medical care institutions for the abovementioned deductions.

1The Insurer shall suspend the contract for one month if the contracted medical care institution has any of the following circumstances during the term of the contract. Notwithstanding, in the case of contracted hospitals, the Insurer may suspend the medical department or specific service item that violates the requirement or the outpatient inpatient services in whole or in part for one month in accordance with the seriousness of the violation.

21. Violation of Article 68 or Paragraph 1 of Article 80 and again after three disciplinary actions by the Insurer;

32. Violation of Article 36 and subject to the punitive measure of three contract-violation points and the same violation again;

43. One of the subparagraphs in the preceding article after medical expenses being deducted three times;

54. Refusal to provide appropriate medical services to insurance beneficiaries and such offense being significant;

1The Insurer may suspend the contract for one to three months if the contracted medical care institution has any of the following circumstances during the term of the contract. Notwithstanding, in the case of contracted hospitals, the Insurer may suspend the medical department or specific service item that violates the requirement or the outpatient inpatient services in whole or in part for one to three months in accordance with the seriousness of the violation.

21. Declaration of medical expenses incurred by non-beneficiaries in the name of beneficiaries;

32. Provision of medications, nutrient supplements, or other items not necessary for treatments to beneficiaries, registration of unnecessary medical services, and declaration of medical expenses;

43. Falsifying medical expenses by forging medical records with no diagnosis or treatment rendered;

54. Other unscrupulous behavior or false certifications, reports, or statements in order to declare medical expenses; or

65. Retention of personnel who are not qualified physicians to provide medical services for beneficiaries and declaring medical expenses by the contracted medical care institution.

1The Insurer shall terminate the contract if the contracted medical care institution has any of the following circumstances. Notwithstanding, in the case of contracted hospitals, the Insurer may suspend the medical department or specific service item that violates the requirement or the outpatient inpatient services in whole or in part for one year in accordance with the seriousness of the violation.

21. Contracted medical care institutions or their responsible medical personnel has been suspended pursuant to the preceding Article, and the same offense was found within five years after the completion of such suspension;

32. Unscrupulous behavior or false certifications, reports, or statements to declare medical expenses and such offense being significant;

43. Violation of medical laws and regulations and practicing licenses revoked by the competent health authority;

54. The contracted medical care institution retains personnel who are not qualified physicians to provide medical services for beneficiaries and declare medical expenses, which is deemed as a serious violation.

65. Reporting of false dates in order to declare the expenses for medical services rendered to insurance beneficiaries during the period when the contract is suspended or requesting other contracted medical care institutions to declare such expenses;

76. Contract terminated or suspended for a year pursuant to the above subparagraphs 1-5, and aforesaid offenses found within one year of resumed contracting after the previous contract termination or suspension of the contract.

8No application for contracting is permitted within one year after the termination of the contract pursuant to the preceding paragraph.

Where the Insurer has imposed disciplinary actions on the contracted medical care institution which has the conduct set forth in Paragraph 1 of Article 81 of the Act pursuant to Subparagraphs 2 and 4 of Paragraph 1 of the preceding article, the Insurer shall publicize the name of the institution, the name of the responsible medical personnel or the person committing the violation as well as the facts of the violation on its website between the issuance of the disciplinary letter and the termination of the disciplinary actions.

1Where the suspension or termination of a contract pursuant to Articles 38 to 40 poses a threat of significant impact on the beneficiaries’ right to receive medical care or is necessary to prevent or mitigate risks to the public, the contract contracted medical care institution, subject to the Insurer’s approval and within the scope of disciplinary, may apply to the Insurer for the deduction of the payment to offset the suspended or terminated contract period according to the declared volume of the medical department or specific service item which is subject to the disciplinary actions or the outpatient, inpatient services in whole or in part as well as the verified average points of the total volume of the district of the most recent year.

2The preceding paragraph governing contractual suspension or termination is applicable to the pending cases not yet implemented before the effect data of the Regulations on September 15, 2010.

1Significant offenses referred to in Subparagraphs 2 and 4 of Paragraph 1 of Article 40 of any of the following circumstances:

21. Falsely reported over 100,000 points and providing beneficiaries with non-medically necessary medications, nutritional supplements, or other items;

32. Falsely reported over 100,000 points, collecting National Health Insurance Cards, recording medical visits, and claiming medical expenses for beneficiaries who were not treated;

43. Falsely reported over 150,000 points and falsely reporting hospital treatment for beneficiaries;

54. Falsely reported over 250,000 points.

If the competent health authority suspends the operations of contracted medical care institutions as a result of the violation of medical care laws and regulations, the contract shall be suspended during this period. If the operations of contracted medical care institutions are terminated or relocated, the contract shall be terminated. However, this does not apply to situations whereby a notice has been sent to the Insurer with changed practicing licenses of the same contracted medical care institution moving to another address in the same township, district, or city.

1Contract shall be terminated should contracted medical care institutions be found under either of the following circumstances:

21. Violation of medical care laws and regulations, the practicing licenses were accordingly revoked by the health competent authority;

32. Subparagraph 2 or Subparagraph 3 of Paragraph 1 of Article 5.

Article 37 to 40 may not apply in the event that the contracted medical care institution voluntarily reports to the Insurer any incorrect information in its filed declaration or confesses to other authorities by returning the relevant expenses (or deductions) prior to the inspection visit conducted by the Insurer or other agencies. The same shall apply to the responsible medical personnel or the medical personnel liable for the conduct who have the above circumstance.

1For any contracted medical care institution whose contract is suspended or terminated, the responsible or liable medical personnel shall not be reimbursed for the medical services they provide to insurance beneficiaries during suspension or within one year after termination.

2The medical personnel whose expenses are not reimbursed are deemed to be subject to the disciplinary act of contract suspension or termination.

1If contracted medical care institutions do not accept the disciplinary actions taken by the Insurer pursuant to the Regulations, they may request in writing for a second review within thirty days after they have received the notice. However, such a request can only be made once.

2The Insurer shall revisit the pending case within thirty days after the aforesaid application has been received. They shall change or rescind the original decision if the reason is justified.

If there are any outstanding insurance premiums and/or any overdue charges due from contracted medical care institutions, and such an outstanding debt remains unpaid after follow-up notices, the Insurer shall be entitled to offset the overdue outstanding with payable medical costs and expenses.

1Where the franchise contract has been suspended or terminated prior to the effective date of the amended Regulations on December 30, 2002, such suspension or termination event shall not be included in the accumulation of the times of contract suspension or termination as required in Subparagraph 2 of Article 45.

2The calculation of the times of contract suspension or termination pursuant to Subparagraphs 2 and 3 of Paragraph 1 of Article 5, Paragraph 4 of Article 5, and Subparagraph 2 of Article 45 for the cases before the effective date of the amended Regulations on September 15, 2010, is on the basis of one time per contracted medical care institution or its medical personnel. Contract suspension is not included in the disciplinary action, which covers both contract suspension and termination.

In rendering the disciplinary decision according to these regulations, adequate consideration shall be accorded to the violation of legal obligation, purpose, degree of fault, and implications as the basis of the handling of breach of contract.

The Regulations shall enter into force on January 1, 2013.