(2023-08-16-ны өдрийн хуулийн орчуулга)                                           Unofficial translation

LAW OF MONGOLIA

January 29, 2015                              Ulaanbaatar city

ON HEALTH INSURANCE

/Revised edition/

CHAPTER ONE

GENERAL PROVISIONS

Article 1.Purpose of the Law

1.1.The purpose of this Law is to establish the principles and scope of mandatory health insurance, to pay premiums for health insurance upon being covered under the health insurance by every citizen of Mongolia in accordance with the law, to create a fund to share the financial risks that may arise due to health among the insured, to distribute and spend the assets of the respective fund, and to regulate the relations to be arisen between the health insurance organization, the health care and service provider organization, the state, and citizens.

Article 2.Legislation on health insurance

2.1.The legislation on health insurance shall consist of the Constitution of Mongolia, the Law on Health, the Law on Medicines and Medical Devices, the Law on Insurance, the General Law on Social Insurance, the Law on Social Welfare, the Law on State Inspection, the Law on State Audit, the Law on the Budget, the Law on the Human Development Fund, this Law, and other legislative acts issued in conformity with them.

/This paragraph was amended by the law as of February 5, 2016/

/In this paragraph, the term "Law on Social Insurance" was amended into the term "General Law on Social Insurance" by the law as of July 7, 2023 and it shall enter into force on January 1, 2024/

Article 3.Definitions of the terms of the Law

3.1.The following terms used in this Law shall have the following meanings:

3.1.1."health insurance" means the activities creating in advance the health insurance fund upon paying the health insurance premiums by the state, citizens, and legal entities in accordance with the procedures prescribed by law, and purchasing the health care and services;

3.1.2."insured" means a citizen with a right to share the financial risks that may arise due to health from the health insurance fund upon regularly paying premiums to the health insurance fund in advance according to this Law;

3.1.3."health insurance organization" means a legal entity that collects the assets of the health insurance fund and being engaged in purchasing activities of the health care and services on behalf of the insured;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

3.1.4."health care and service provider organization" means a health care organization and a pharmacy that have signed a contract with a health insurance organization;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of July 6, 2017/

/This sub-paragraph was amended by the law as of November 10, 2017/

/This sub-paragraph was amended by the law as of August 28, 2020/

3.1.5."health insurance premium" means the payment to be paid at the rate prescribed by law to the health insurance fund by the citizens and by the state and legal entities on behalf of them in order to be covered under the health insurance;

3.1.6."health insurance fund" means monetary assets accumulated from the income of the premiums paid by the state, citizens, and legal entities for the purpose of sharing the financial risks that may incur to the insured due to health, and other sources;

3.1.7."package of health care and services which costs to be paid by the health insurance fund" means comprehensive health care and service including diagnosis, early detection, treatment, rehabilitation, care, nursing, palliative care, and medicine price discounts to be provided to the insured essentially;

/This sub-paragraph was amended by the law as of July 6, 2017/

/This sub-paragraph was amended by the law as of August 28, 2020/

3.1.8."insurance contract" means the contract concluded between the health insurance organization and the health care and service provider organization;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of July 6, 2017/

/This sub-paragraph was amended by the law as of November 10, 2017/

/This sub-paragraph was amended by the law as of August 28, 2020/

3.1.9."payment method" means the form of settlement to be paid by the health insurance fund for the payment of health care and service expenses;

3.1.10."electronic card" means the electronic certificate issued by the health insurance organization to the insured containing information on the health insurance premiums paid by the insured, and the health care and services received;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

3.1.11."voluntary additional health insurance" means to be insured voluntarily by a citizen to a non-state property insurance organization being engaged in health insurance activities in order to receive care and services that are not included in the package of health care and services for which the expenses to be paid by the health insurance fund specified in Article 9 of this Law.

Article 4.Types of health insurance

4.1.Health insurance shall have the types of mandatory and voluntary additional insurance.

4.2.Mongolian citizens shall be insured with mandatory health insurance in order to share the financial risks that may arise due to health.

4.3.Foreign citizens and stateless persons specified in Paragraphs 7.2, 7.3, 7.4, 7.5, and 7.6 of Article 7 of the General Law on Social Insurance shall be insured with mandatory health insurance, unless otherwise specified in the international treaties of Mongolia.

/In this paragraph, the term "Paragraph 2 of Article 4 of the Law on Social Insurance" was amended into the term "Paragraphs 7.2, 7.3, 7.4, 7.5, and 7.6 of Article 7 of the General Law on Social Insurance" by the law as of July 7, 2023 and it shall enter into force on January 1, 2024/

4.4.Except as specified in paragraph 4.3 of this Law, foreign citizens and stateless persons may be insured with mandatory health insurance if they wish.

4.5.Mandatory health insurance activities shall be carried out by the health insurance organization.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

4.6.Citizens can be insured for additional voluntary health insurance in order to receive care and services that are not included in the package of health care and services for which expenses to be paid from the health insurance fund specified in Article 9 of this Law.

4.7.Voluntary additional health insurance activities shall be carried out by a non-state property insurance organization with a special permit.

4.8. Voluntary additional health insurance relations shall be governed by this Law and the Law on Insurance.

Article 5.Principles of mandatory health insurance

5.1.Mandatory health insurance /hereinafter referred to as "health insurance"/ shall be based on the principle of solidarity in sharing the financial risks caused to the insured due to the health, regardless of the amount of the premium paid by the insured.

5.2.The health care and services specified in Article 9 of this Law shall be in compliance with the health needs and requirements of the insured, based on the evidence, of good quality, safe, equal and accessible.

5.3.Organizations operating in the territory of Mongolia and specified in sub-paragraph 3.1.4 of this Law shall provide health care and services specified in Article 9 of this Law.

5.4.Citizens, the state, and legal entities shall be responsible for health insurance premiums in accordance with the grounds and procedures specified in this Law and other relevant laws.

CHAPTER TWO

THE INSURED AND HIS/HER RIGHTS AND OBLIGATIONS

Article 6.Population group to be covered under the health insurance

6.1.The population shall be classified as follows according to the status of paying health insurance premiums:

6.1.1.an employee specified in Paragraphs 7.2, 7.3, 7.4, 7.5, and 7.6 of Article 7 of the General Law on Social Insurance

/In this sub-paragraph, the term "Paragraph 2 of Article 4 of the Law on Social Insurance" was amended into the term "Paragraphs 7.2, 7.3, 7.4, 7.5, and 7.6 of Article 7 of the General Law on Social Insurance" by the law as of July 7, 2023 and it shall enter into force on January 1, 2024/

6.1.2.self-employed citizen;

6.1.3.herdsman;

6.1.4.a foreign citizen or stateless person specified in paragraph 4.4 of this Law;

6.1.5.children aged 0-18;

6.1.6.a citizen who has no regular monetary income other than pension;

6.1.7.family member-citizen in need of social welfare support and assistance;

6.1.8.a mother /father/ who is raising a child up to the age of two (if twins up to three);

6.1.9.students of universities, colleges, vocational training-production centers;

6.1.10.full-time military personnel;

6.1.11.a convict serving a sentence;

6.1.12.citizens other than those specified in sub-paragraphs 6.1.1-6.1.11 of this Law.

Article 7.Rights and obligations of the insured

7.1.The insured shall have the following rights:

7.1.1.receive of good quality, safe, equal and accessible health care and services;

7.1.2.be paid the cost of health care and services specified in Article 9 of this Law from the health insurance fund in the amount determined in accordance with this Law;

7.1.3.choose and obtain services from all types of health care and service providers that have signed a contract with the health insurance organization;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

7.1.4.get information about health insurance from health insurance organizations, health care and service provider organizations, and other organizations involved in health insurance relations;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

7.1.5.be issued a receipt for directly paid health care and services by him/herself from the health care and service provider;

7.1.6.submit and resolve complaints to competent legal entities such as the National Health Insurance Council /hereinafter referred to as "the National Council" and health insurance organizations on issues related to health insurance;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

/This sub-paragraph was amended by the law as of November 11, 2022/

7.1.7.monitor the quality, payment of expenses, and payment discounts of health care and services;

7.1.8.in the event that the payment of the insured's health care and service expenses specified in sub-paragraphs 6.1.1,-6.1.4, 6.1.9, and 6.1.12 of this Law exceeds the maximum limit for the current year, with the consent of another insured member of the family, transfer estimation from its expenses once a year;

/This sub-paragraph was invalidated by the law as of August 28, 2020/

7.1.9.monitor electronically the records of paid health insurance premiums and information on the received health care and services;

7.1.10.recover overpaid health insurance premiums, or count them as health insurance premiums to be paid later;

7.1.11.other rights provided by laws.

7.2.The insured shall have the following obligations:

7.2.1.pay health insurance premiums within the time limit set by this Law;

7.2.2.accurately declare the amount of wages and income equivalent to be imposed the health insurance premiums;

7.2.3.fulfill legal requirements set by health insurance organizations and state inspectors;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

7.2.4.other obligations provided by laws.

CHAPTER THREE

HEALTH INSURANCE PREMIUMS TO BE PAID BY THE INSURED AND HEALTH CARE AND SERVICES TO BE PROVIDED TO THE INSURED

Article 8.Rate of health insurance premiums and its payment procedure

8.1.Based on the proposal of the National Council, the Government shall determine the rate of health insurance premium (hereinafter referred to as "premium") of the insured specified in Article 6.1 of this Law as follows:

8.1.1.the rate of monthly premiums to be paid by the insured as specified in sub-paragraph 6.1.1 of this Law shall be not less than 4 percent of his/her wages and/or income equivalent to every year;

8.1.2.the rate of monthly premiums to be paid by the insured as specified in sub-paragraphs 6.1.2, 6.1.3, 6.1.5, 6.1.9, and 6.1.12 of this Law shall be not less than 1 percent of the monthly minimum wage every year;

/This sub-paragraph was amended by the law as of November 10, 2017/

8.1.3.the rate of monthly premiums to be paid by the insured except as specified in sub-paragraphs 6.1.1, 6.1.2, 6.1.3, 6.1.5, 6.1.9, and 6.1.12 of this Law shall be not less than 2 percent of the monthly minimum wage every year.

/This sub-paragraph was amended by the law as of November 10, 2017/

8.2.The premium shall be paid to the health insurance fund as follows:

8.2.1.the premium of the insured specified in sub-paragraph 6.1.1 of this Law shall be paid by the insured and the employer in equal proportions every month;

8.2.2.the premiums of the insured specified in sub-paragraphs 6.1.2-6.1.4 and 6.1.12 of this Law shall be paid by him/herself semi-annually or annually;

/This sub-paragraph was amended by the law as of November 10, 2016/

8.2.3.the premium of the insured specified in sub-paragraph 6.1.5-6.1.8 and 6.1.10 of this Law shall be paid from the state budget every month;

8.2.4.the premiums of the insured specified in sub-paragraph 6.1.9 of this Law shall be paid by him/herself semi-annually or annually;

/This sub-paragraph was amended by the law as of November 10, 2016/

8.2.5.the premium of the insured specified in sub-paragraph 6.1.11 of this Law shall be paid by the penitentiary institution every month.

8.3.The following person shall be responsible for paying the insured's premium specified in paragraph 8.2 of this Law to the health insurance fund:

8.3.1.the employer of the insured specified in sub-paragraph 6.1.1 of this Law;

8.3.2.the insurer in accordance with the agreement signed by the Governor of the baghs and khoroo's of the insured specified in sub-paragraph 6.1.3 of this Law;

8.3.3.the school administration of the insured specified in sub-paragraph 6.1.9 of this Law;

8.3.4.military units and squads of the insured specified in sub-paragraph 6.1.10 of this Law.

Article 9.Health care and services to be provided to the insured

9.1.The package of health care and services of which expenses to be paid by the Health Insurance Fund shall include the following cares and services:

9.1.1.inpatient care and services;

9.1.2.ambulatory examination, control, diagnosis, analysis and treatment;

9.1.3.treatment and services for day;

9.1.4.palliative care and services for cancer and other diseases;

/This sub-paragraph was invalidated by the law as of August 28, 2020/

9.1.5.care and services to be provided by health care institutions specified in sub-paragraphs 15.1.3, 15.1.8, 15.1.10, and 15.1.14 of the Law on Health;

/This sub-paragraph was modified by the law as of August 28, 2020/

9.1.6.some high-cost care and services, necessary medical equipment;

/This sub-paragraph was invalidated by the law as of August 28, 2020/

9.1.7.discount on the price of prescription medicine prescribed by a doctor of health care institution as specified in sub-paragraphs 15.1.1, 15.1.2, 15.1.4, 15.1.5, 15.1.7, 15.1.9, 15.1.11, and 15.1.13 of the Law on Health;

/This sub-paragraph was modified by the law as of August 28, 2020/

9.1.8.certain types of artificial valves, prostheses and orthopedic devices for reconstruction;

/This sub-paragraph was invalidated by the law as of August 28, 2020/

9.1.9.certain rehabilitation services, home care and services, day treatment, diagnosis and analysis provided by the family, soum, and village health centers;

9.1.10.chemical and radiation day treatment of cancer;

9.1.11.treatment of comorbidities before and after 37 weeks of pregnancy;

9.1.12.active movement and sports services at an accredited sports club;

/This sub-paragraph was added by the law as of July 6, 2017/

/This sub-paragraph was invalidated by the law as of August 28, 2020/

9.1.13.medical care and services specified in sub-paragraphs 24.6.1, 24.6.2, 24.6.5-24.6.8, 24.6.10, and 351.3 of the Law on Health;

/This sub-paragraph was added by the law as of August 28, 2020/

9.1.14.forensic hospital outpatient examination;

/This sub-paragraph was added by the law as of December 23, 2022/

9.1.15.forensic examination of dead bodies.

/This sub-paragraph was added by the law as of December 23, 2022/

9.2.The health care and service provider organization that has signed a contract with the health insurance organization shall provide health care and services of that level to the insured regardless of their jurisdiction.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

9.3.A price discount may be given if the insured purchases the generic name medicines included in the list of necessary medicines to be discounted by the health insurance fund with the prescription written by the doctor of the health care institution as specified in sub-paragraphs 15.1.1, 15.1.2, 15.1.4, 15.1.5, 15.1.7, 15.1.9, 15.1.11, and 15.1.13 of the Law on Health, from the pharmacy of the respective health care institutions or other pharmacies.

/This paragraph was modified by the law as of August 28, 2020/

9.4.The coverage of the insured under the preventive and early detection examinations, diagnosis, tests, and immunization against infectious diseases at the scheduled time based on his/her age, gender, and health risk shall be conducted, and the payment of the cost thereto shall be financed from the health insurance fund, and the relevant procedures shall be approved by the National Council based on the proposal of the state central administrative bodies in charge of financial, budgetary and health affairs.

/This paragraph was amended by the law as of July 6, 2017/

/This paragraph was amended by the law as of November 10, 2017/

/This paragraph was modified by the law as of August 28, 2020/

9.5.Preventive and early detection examinations, diagnostics, tests, and other health care and services organized as a public campaign shall not be financed by the health insurance fund.

9.6.The payment of the cost of care and services specified in sub-paragraphs 9.1.6-9.1.8 of this Law shall not apply to the insured specified in sub-paragraph 6.1.4 of this Law.

/This paragraph was added by the law as of November 10, 2016/

CHAPTER FOUR

PAYMENT OF HEALTH CARE AND SERVICE EXPENSES

Article 10.Conclusion of insurance contract

10.1.The health insurance organization shall enter into an insurance contract (hereinafter referred to as "contract") with the health care and service provider organization and the pharmacy that have passed the selection process specified in sub-paragraph 16.1.4 of this Law, and monitor and evaluate the implementation of the contract.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

/This paragraph was amended by the law as of August 28, 2020/

10.2.The contract shall clearly state the budget, type, quantity, quality criteria, payment method, and payment amount of the health care and services specified in the Article 9 of this law, as well as the contract period, the obligations and responsibilities of the parties to the contract, and the conditions for terminating the contract.

10.3.The model of the contract shall be approved by the National Council.

Article 11.Payment of health care and service expenses

11.1.The health insurance fund and the insured shall jointly pay the payment of the expenses of health care and services specified in Article 9 of this Law.

11.2.Amount of payment, payment methods and procedures to be paid by the health insurance fund and the insured for the expenses of health care and services specified in Article 9 of this Law shall be determined by the National Council based on the proposals of the health insurance organization and the state central administrative bodies in charge of financial, budgetary and health affairs, respectively.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

/This paragraph was amended by the law as of August 28, 2020/

11.3.The health insurance organization shall issue the payment of the cost of health care and services provided to the insured in accordance with Article 9 of this Law upon calculating it by performance based on the monthly schedule of the budget thereto, and the health insurance organization may grant an advance payment of costs to the health care and service provider organization in accordance with the contract specified in Article 10 of this Law.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

/This paragraph was amended by the law as of August 28, 2020/

11.4.The increase of the payment of expenses to be spent for health care and services from the health insurance fund shall not be a ground to reduce the funding to be provided by the state budget for health care and services.

Article 12.Reimbursement of health care and service expenses

12.1.The following expenses shall be reimbursed by the person mentioned below:

12.1.1.the payment of the health care and service expenses of the insured whose health was damaged due to a crime or violation shall be paid by the guilty person under the responsibility of the law enforcement organizations to the health insurance institution;

/This sub-paragraph was amended by the law as of November 10, 2016/

12.1.2.in case it is determined that diagnosis and treatment complications have occurred due to the wrongful actions of a medical specialist, health care or service provider organization, the expenses of health care or services shall be paid by the respective health care or service provider organization to the insured.

Article 13.Rights and obligations of health care and service provider organizations

13.1.The health care and service provider organization shall have the following rights and obligations:

13.1.1.be paid the payment of the expenses of health care and services specified in Article 9 of this Law provided to the insured from the health insurance fund;

13.1.2.sign a contract with a health insurance organization and ensure its implementation;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

13.1.3.provide equal, accessible, high-quality and fast health care and services to the insured, and to provide with relevant information to the insured;

13.1.4.record and store the name, type, form, quantity, cost and other information of health care and services provided to the insured, and report to the health insurance organization;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

13.1.5.compensate the insured for damages caused by the fault of the employee of the health care and service provider organization in accordance with the law;

13.1.6.prepare statements, estimations and related documents of the payment of the insureds to be paid by the health insurance fund accurately and in timely manner, and submit them to the health insurance organization;

13.1.7.formulate proposals on issues in connection with activities of the health insurance organizations and be resolved it by delivering through their representatives in the National Council;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

13.1.8.during hospitalization of the insured, if the cost of medicines and medical devices recorded in the medical history paid by him/herself, they shall be reimbursed to the insured at the standard market price;

/This sub-paragraph was amended by the law as of August 28, 2020/

13.1.9.deduct from the payment to be paid by the insured at the amount of the payment of  the cost of health care and services to be paid by the health insurance fund;

13.1.10.in case of violation of legislation on health insurance, to fulfill the legal requirements set by competent organizations and officials to eliminate the respective violation;

13.1.11.prohibit the provision of unnecessary inpatient treatment and other health care and services, referral assistance and dispensing of medicines;

13.1.12.other rights and obligations provided by laws.

CHAPTER FIVE

SYSTEM OF THE HEALTH INSURANCE ORGANIZATION

Article 14.National Council of Health Insurance

14.1.The system of the health insurance organization shall consist of the National Council, the state central administrative and the state administrative bodies in charge of health insurance affairs, social insurance departments of aimags and districts, and health insurance inspectors of soums as specified in Article 27 of the Law on Social Insurance.

/This paragraph was modified by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2016/

/This paragraph was amended by the law as of November 10, 2017/

14.2.The highest governing body of health insurance shall be the National Council.

/This paragraph was invalidated by the law as of July 21, 2016/

14.3.The National Council shall have the following composition and shall report its work to the State Great Khural every year:

14.3.1.representing the Government, one person each from the state central administrative body in charge of finance, budget, social insurance and health affairs;

14.3.2.three persons representing the organization that protects the rights and legal interests of the majority of the insured;

14.3.3.three persons representing the organization representing the rights and legal interests of the majority of employers.

/This paragraph was invalidated by the law as of July 21, 2016/

14.4.The Chairman, Deputy Chairman and members of the National Council shall be appointed and dismissed by the State Great Khural for a period of five years based on the proposals of the parties, and may be reappointed once.

/This paragraph was invalidated by the law as of July 21, 2016/

14.5.The rules of the National Council shall be approved by the relevant Standing Committee of the State Great Khural.

/This paragraph was invalidated by the law as of July 21, 2016/

14.6.The National Council shall have an office, and the staff and working rules of the office shall be approved by the relevant Standing Committee of the State Great Khural.

/This paragraph was invalidated by the law as of July 21, 2016/

14.7.The members of the National Council shall be given a quarterly salary increase based on their work participation, and the maximum salary increase shall be determined by the relevant Standing Committee of the State Great Khural based on the proposal of the state central administrative body in charge of social insurance affairs.

/This paragraph was invalidated by the law as of July 21, 2016/

14.8.The National Council shall have the following rights:

14.8.1.approve the structure and charter of the health insurance organization;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

14.8.2.approve the procedures for calculating, placing in the state treasury and spending the assets of the health insurance risk fund based on the proposal of the state central administrative bodies in charge of financial, budgetary and health affairs;

/This sub-paragraph was modified by the law as of August 28, 2020/

14.8.3.approve the procedure for placing in the state treasury and spending the free balance of the health insurance fund based on the proposal of the state central administrative bodies in charge of financial, budgetary and health affairs;

/This sub-paragraph was modified by the law as of August 28, 2020/

14.8.4.discuss and resolve issues submitted by relevant organizations regarding improvement of the legislation on health insurance, health insurance system and operations, develop proposals, and make decisions by competent persons;

14.8.5.establish permanent and temporary working groups involving professional societies, associations, experts, the insureds, and partner parties on issues in connection with the health insurance, and discuss the results of the work;

14.8.6.issue relevant procedures, resolutions, and recommendations within the scope of his/her powers on issues in connection with the health insurance;

14.8.7.approve the procedures for quality and payment control of health care and services purchased under the insurance contract using international medical guidelines;

/This sub-paragraph was added by the law as of August 28, 2020/

14.8.8.other powers provided by legislation.

/This sub-paragraph was amended by the law as of August 28, 2020/

14.9.The National Council shall have the following obligations:

14.9.1.develop the budget project, projection, and budget framework statement of operating expenses of the health insurance fund and health insurance organization based on actuarial estimations, approve the detailed schedule of the approved budget, and supervise its performance;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

14.9.2.discuss the activity reports of the health insurance fund and health insurance organization, monitor operational and management costs, give evaluations and opinions;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

14.9.3.approve the list of care and services to be included in the package of health care and services for which the health insurance fund will be responsible for the payment of expenses specified in paragraph 9.1 of this Law based on the proposal of the state central administrative bodies in charge of health and social insurance affairs;

/This sub-paragraph was removed by the law as of July 21, 2016/

14.9.4.set the maximum payment limit for health care and services to be provided to the insured by the health insurance fund, and the amount of payment to be paid by the insured specified in paragraph 11.2 of this Law, based on the proposal of the state central administrative bodies in charge of social insurance and health affairs;

/This sub-paragraph was removed by the law as of July 21, 2016/

14.9.5.determine the types of essential medicines, maximum price limits, and discount amounts for price discounts to be paid from the health insurance fund based on the proposal of the state central administrative bodies in charge of social insurance and health issues;

/This sub-paragraph was removed by the law as of July 21, 2016/

14.9.6.approve the procedure for selection of organizations providing health care and services based on the proposal of the state central administrative bodies in charge of social insurance and health affairs;

/This sub-paragraph was removed by the law as of July 21, 2016/

14.9.7.resolve applications and complaints submitted on issues related to health insurance;

14.9.8.approve the list of care and services to be included in the package of health care and services for which the Health Insurance Fund to be responsible for the cost payment specified in paragraph 9.1 of this Law based on the proposal of the state central administrative bodies in charge of health and financial and budgetary affairs;

/This sub-paragraph was added by the law as of November 10, 2016/

/This sub-paragraph was amended by the law as of August 28, 2020/

14.9.9.establish the maximum payment limit to be paid by the Health Insurance Fund for health care and services to be provided to the insured, and the amount of payment to be paid by the insured specified in paragraph 11.2 of this Law based on the proposal of the state central administrative bodies in charge of social insurance and health affairs;

/This sub-paragraph was added by the law as of November 10, 2016/

/This sub-paragraph was invalidated by the law as of August 28, 2020/

14.9.10.determine the types, the maximum price limit, and the amount of the discount of essential medicines to be made price discount from the health insurance fund based on the proposal of the state central administrative bodies in charge of financial, budgetary and health affairs;

/This sub-paragraph was added by the law as of November 10, 2016/

/This sub-paragraph was amended by the law as of August 28, 2020/

14.9.11.approve the procedure for the selection of organizations providing health care and services based on the proposal of the state central administrative body in charge of financial, budgetary and health affairs;

/This sub-paragraph was added by the law as of November 10, 2016/

/This sub-paragraph was amended by the law as of August 28, 2020/

14.9.12.establish a non-staff technical committee with the responsibility of making conclusions and recommendations on health care and service packages, payment amounts, quality and financial control issues with the participation of experts and researchers specialized in the respective matter, the health care and service provider organizations, and the insureds, approve its work procedures, and make the relevant decisions based on the conclusions and recommendations of the technical committee;

/This sub-paragraph was added by the law as of August 28, 2020/

14.9.13.other obligations provided by legislation.

/The numbering of this sub-paragraph was amended by the law as of November 10, 2016/

/The numbering of this sub-paragraph was amended into the numbering "14.9.13" by the law as of August 28, 2020/

14.10.The National Council shall hold a meeting at least twice per quarter, if necessary, by the chairman or the majority of the members, and the meeting shall be convened with the attendance of at least two-thirds of the voting members who have full participation.

14.11.The Chairman, Deputy Chairman and members of the National Council shall be dismissed on the following grounds:

14.11.1.failed to fulfill their duties repeatedly and became unable to perform their duties;

14.11.2.was absent three times in a row without valid reasons to the meeting;

14.11.3.submitted a request for exemption before the full term of office expires;

14.11.4.convicted a crime and has been found guilty by a court;

14.11.5.the being represented party has withdrawn him/her;

14.11.6.death of a member and other grounds for exemption established by law.

14.12.The Chairman, Deputy Chairman and member of the National Council may be relieved of their duties by the State Great Khural based on the reasonably justified written request of at least two-thirds of the members of the National Council.

14.13.The Chairman, Deputy Chairman and member of the National Council shall submit their resignation request to the relevant Standing Committee of the State Great Khural before the end of their term of office.

Article 141.Composition of the National Council

141.1.The highest governing body of health insurance shall be the National Council.

141.2.The National Council shall have the following composition and shall report its work to the State Great Khural every year:

141.2.1.representing the Government, one person each from the state central administrative bodies in charge of finance, budget, social insurance and health affairs;

141.2.2.three persons representing the organization that protects the rights and legal interests of the majority of the insured;

141.2.3.three persons representing the organization that protects the rights and legal interests of the majority of the employer.

141.3.The Chairman, Deputy Chairman and members of the National Council shall be appointed and dismissed for a term of five years by the State Great Khural upon conducting the public hearing of the candidates based on the proposals of the parties, and may be reappointed once.

/This paragraph was amended by the law as of December 24, 2021/

141.4.The charter of the National Council shall be approved by the relevant Standing Committee of the State Great Khural.

141.5.The National Council shall have an office.

/This paragraph was modified by the law as of November 10, 2017/

141.6.A member of the National Council shall be given a quarterly bonus based on their work participation, and the maximum amount of the bonus shall be determined by the relevant Standing Committee of the State Great Khural based on the proposal of the state central administrative body in charge of health insurance affairs.

/This paragraph was amended by the law as of November 10, 2017/

/This Article was added by the law as of November 10, 2016/

Article 15.Health insurance organization and its management

15.1.The health insurance organization shall be the implementing agency of the Government, and the local branches and units of health insurance shall operate under the management of the health insurance organization.

15.2.The head of the health insurance organization shall be appointed and dismissed by the Cabinet member in charge of social insurance based on the proposal of the National Council.

15.3.The head of the health insurance organization shall meet the conditions specified in Article 16 of the Law on Civil Service.

15.4.The head of the local branch of health insurance shall be appointed and dismissed by the head of the health insurance organization after selecting from the employees who have worked in the social insurance or health insurance organization for at least three years.

15.5.The health insurance employee of the soum shall be appointed and dismissed by the head of the local branch.

/This Article was invalidated by the law as of July 21, 2016/

Article 151.Health insurance organization and its management

151.1.The health insurance organization shall be the implementing agency of the Government, and the local branches and units of health insurance shall operate under the management of the health insurance organization.

151.2.The head of the health insurance organization shall be appointed and dismissed in accordance with the procedure specified in Article 183 of the Law on the Government of Mongolia.

/This paragraph was modified by the law as of July 7, 2020/

151.3.The head of the health insurance organization shall meet the conditions specified in Article 16 of the Law on Civil Service.

151.4.The head of the local branch of health insurance shall be selected from the employees who have worked in the social insurance or health insurance organization for at least three years, and shall be appointed and dismissed by the head of the health insurance organization.

/This Article was added by the law as of November 10, 2016/

Article 16.Functions of the health insurance organization

/The title of this Article was amended by the law as of July 21, 2016/

/The title of this Article was amended by the law as of November 10, 2017/

16.1.The health insurance organization shall perform the following functions:

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

16.1.1.organize the implementation of legislation on health insurance;

16.1.2.accumulat a health insurance fund, ensure the balance of income and expenditure, and report on activities;

16.1.3.on behalf of the insured, conclude an insurance contract for the purchase of care and services with a health care and service provider organization, monitor and evaluate the fulfillment of the contract;

/This sub-paragraph was modified by the law as of August 28, 2020/

16.1.4.organize a selection process according to the procedure specified in sub-paragraph 14.9.11 of this Law among the health care and service provider organizations by taking into account of the quality, safety, and accessibility of their care and services except the licensed and accredited pharmacies of all types of ownership operating in the territory of Mongolia;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was modified by the law as of November 10, 2016/

/This sub-paragraph was amended by the law as of August 28, 2020/

16.1.5.monitor the quality and payment of the cost of health care and services to be provided to the insured, and provide payment for health care and services that meet the criteria specified in the procedures stated in sub-paragraph 14.8.7 of this Law;

/This sub-paragraph was modified by the law as of August 28, 2020/

16.1.6.formulate proposals on issues specified in sub-paragraphs 14.9.1, 14.9.8-14.9.11 of this Law, and be decided them by the National Council in consultation with the relevant state central administrative body;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2016/

16.1.7.conduct financial control over the income and expenditure of the health insurance fund;

16.1.8.create an integrated health insurance database and introduce advanced information technology;

16.1.9.provide the National Council and other competent persons with information, calculations, and research necessary for the exercise of their powers, and to support their activities;

16.1.10.conduct calculation and research necessary for development the health insurance, improvement of insurance operations, and for determining the results, costs, and premiums rates of health care and services, formulate proposals thereto, and forward them to competent persons;

16.1.11.promote publicly the legislation on health insurance and health insurance activities, provide the insured with necessary information;

16.1.12.receive and resolve suggestions and complaints related to the quality and accessibility of health care and services to be provided to the insured;

16.1.13.approve the procedure for awarding incentives specified in sub-paragraph 20.1.3 of this Law to health care and service provider organizations;

16.1.14.approve procedures for invoicing, monitoring, settlement, and dispute resolution for the payment of the expenses of the health  care and services provided to the insured;

16.1.15.approve the procedure for discounting the price of prescription medicines by the health insurance fund;

16.1.16.issue procedures, methodologies, and instructions on health insurance issues;

16.1.17.notify the insured in advance of the appointment period for the preventive and early detection examination, diagnosis, and analysis specified in paragraph 9.4 of this Law;

16.1.18.other functions provided by legislation.

16.2.The purchase of certain health care and services for which the state to be responsible shall be performed by the health insurance organization by stage by stage based on the contract.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

/This paragraph was invalidated by the law as of August 28, 2020/

16.3.The Government shall approve the procedures related to the implementation of activities specified in paragraph 16.2 of this Law.

/This paragraph was invalidated by the law as of August 28, 2020/

Article 17.Rights, obligations and liabilities of the state health insurance inspector

/The title of this Article was amended by the law as of July 21, 2016/

/The title of this Article was amended by the law as of November 10, 2017/

17.1.The head of the health insurance organization shall grant, suspend or revoke the right of state inspector to an employee with a high professional degree who has worked in the social insurance or health insurance organization for at least two years.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

17.2.The working rules of the state health insurance inspector shall be approved by the head of the health insurance organization.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

17.3.The state health insurance inspector shall have the following rights and obligations:

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

17.3.1.inspect, receive explanation and inquiries about medical records, medical cards, diagnoses, tests, treatment, and other financial documents relevant to the health care and services provided to the insured;

/This sub-paragraph was amended by the law as of November 10, 2016/

17.3.2.issue copies of documents required for health insurance inspection free of charge from the relevant organization;

17.3.3.monitor the quality, payment of costs, and results of health care and services, make conclusions, and give recommendations;

17.3.4.impose the liability specified in the legislation on the officials who violated the relevant standards and guidelines, causing damage to the insured's health, providing treatment, care, and services for illegal fees, and, if necessary, to be resolved by the competent authorities;

17.3.5.impose the liability specified in the relevant law on organizations, officials, insureds, and citizens participating in insurance relations who violated the legislation on health insurance, and to inform publicly via press and media means about the actions of the person who repeatedly committed the violation.

/This sub-paragraph was amended by the law as of December 4, 2015/

17.4.The disciplinary, property and criminal liability as specified by legislation shall be imposed on the state insurance inspectors who failed to properly fulfill their official duties by hiding illegal activities related to payment of premiums, using health insurance funds for personal purposes, taking bribes, violating ethical norms, disclosing confidential information, or exceeding their rights.

/This paragraph was amended by the law as of December 4, 2015/

Article 18.Social security, qualification degrees, and increase in qualifications of state health insurance inspectors and specialists

/The title of this Article was amended by the law as of July 21, 2016/

/The title of this Article was amended by the law as of November 10, 2017/

18.1.In the event that a state health insurance inspector or specialist temporarily loses working ability, becomes disabled, or dies while performing his/her duties, the following grants shall be granted to him/her and his/her family:

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

18.1.1.allowance for the period of temporary loss of working ability, difference in basic salary for the position;

18.1.2.disability pension in case of disability, difference in basic salary for the position;

18.1.3.in case of death, a one-time grant to the family equal to three years' basic salary of the victim.

18.2.The grant specified in sub-paragraph 18.1.3 of this Law shall be granted by the organization in which he/she worked, and the guilty party shall be compensated for damages in accordance with the law.

18.3.The state health insurance inspector shall have a qualification degree, and the National Council shall approve the procedure for determining the qualification degree and awarding a qualification degree increase.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

18.4.State health insurance inspectors and specialists shall be given productivity incentives based on the fulfillment of performance criteria and work results, and the relevant procedure shall be approved by the Cabinet member in charge of health affairs.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

/This paragraph was modified by the law as of August 28, 2020/

CHAPTER SIX

HEALTH INSURANCE FUND

Article 19.Sources of health insurance fund income

19.1.The income of the health insurance fund shall consist of the following sources:

19.1.1.health insurance premiums paid by the insured;

19.1.2.health insurance premiums paid by the employer;

19.1.3.premiums paid by the state budget to citizens whose insurance to be responsible by the State;

19.1.4.payments made by the Human Development Fund in accordance with the law;

/This sub-paragraph was invalidated by the law as of February 5, 2016/

19.1.5.funds provided by the state budget to finance the cost of health care and services for which the state is responsible for payment through the health insurance organization;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

19.1.6.interest on the free balance of the fund;

19.1.7.interest on depositing risk reserves;

19.1.8.fines imposed for late payment of health insurance premiums;

19.1.9.other sources.

19.2.The income of the health insurance fund shall be exempted from all types of taxes and fees.

19.3.The social insurance organization shall perform the activities of collecting and concentrating the premiums of the insured belonging to the group to be covered under health insurance specified in sub-paragraphs 6.1.1 and 6.1.11 of this Law, and premiums and fines specified in sub-paragraph 19.1.8 of this Law, and the relations in connection with thereto shall be regulated by the General Law on Social Insurance.

/In this paragraph, the term "Law on Social Insurance" was amended into the term "General Law on Social Insurance", and the term "19.1.1 and 19.1.2" was amended into the term "the premiums of the insured belonging to the group to be covered under health insurance specified in sub-paragraphs 6.1.1 and 6.1.11" by the law as of July 7, 2023 and it shall enter into force on January 1, 2024/

19.4.Funds concentrated by the social insurance organization shall be transferred to the health insurance fund every week.

Article 20.Expenditure of health insurance fund

20.1.The funds of the health insurance fund shall be spent for the following purposes:

20.1.1.purchase health care and services specified in Article 9 of this Law;

20.1.2.purchase some health care and services for which the state is responsible to pay through a health insurance organization;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

/This sub-paragraph was invalidated by the law as of August 28, 2020/

20.1.3.incentive costs to be given to health care and service provider organizations with insurance contracts by considering the quality and results of health care and services;

20.1.4.expenses specified in paragraph 9.4 of this Law;

20.1.5.cost of measures to be implemented by investment of health insurance organization;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

20.1.6.operational costs of the health insurance organization;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

20.1.7.operating costs of the social insurance organization specified in paragraph 19.3 of this Law;

20.1.8.information and advertising costs related to the coverage under health insurance by citizens;

20.1.9.bonuses of members of the National Council specified in Article 141.6 of this Law and operational expenses of the office.

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2016/

20.2.The health insurance risk fund shall be established in an amount equal to 10 percent of the income of the health insurance fund for the current year.

20.3.The expenses specified in sub-paragraphs 20.1.6-20.1.9 of this Law shall not exceed 5 percent of the income of the health insurance fund for the current year.

20.4.The model of the primary accounting form of the health insurance fund shall be jointly approved by the Cabinet members in charge of financial, budgetary and health insurance affairs.

/This paragraph was amended by the law as of November 10, 2017/

20.5.The health insurance risk fund, the income from its deposit located in the state fund, and the free balance of the health insurance fund shall be used to cover the losses of the health insurance fund to be caused due to force majeure as well as the impact of economic and financial difficulties, and to ensure the stability of the fund in accordance with the procedures specified in sub-paragraphs 14.8.2 and 14.8.3 of this Law.

/This paragraph was amended by the law as of August 28, 2020/

Article 21.Approving the income and expenditure budget of the health insurance fund and preparing the balance sheet

21.1.The annual revenue and expenditure budget of the Health Insurance Fund shall be approved by the State Great Khural.

21.2.The National Council shall deliver the budget draft of the health insurance fund to the state central administrative body in charge of financial and budgetary affairs by August 15th of each year.

21.3.The state central administrative body in charge of financial and budgetary affairs shall submit the budget draft of the health insurance fund to the Government.

21.4.The Government shall submit the budget draft of the health insurance fund to the State Great Khural by October 1st of each year.

21.5.The health insurance organization shall prepare the income and expenditure balance of the health insurance fund by quarter and year for the periods mentioned below and report them to the state central administrative body in charge of health insurance affairs and the National Council:

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

21.5.1.income and expenditure reports shall be submitted by the health insurance organizations of soums and districts to the health insurance organization within the 15th of the subsequent month of the respective quarter, and by health insurance organization of the aimags within the 25th of the subsequent month of the respective quarter, respectively;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

21.5.2.the consolidated quarterly report of the health insurance fund shall be submitted by the health insurance organization within the 10th of the subsequent second month of the quarter, and the annual consolidated report within the 25th of February of the subsequent year, together with opinions and conclusions, to the state central administrative body in charge of health insurance affairs;

/This sub-paragraph was amended by the law as of July 21, 2016/

/This sub-paragraph was amended by the law as of November 10, 2017/

21.5.3. the quarterly report shall be submitted by the state central administrative body in charge of health insurance affairs within the 10th of the last months of the subsequent quarter, and the annual report within the first quarter of the subsequent year to be reviewed and discussed at the National Council.

/This sub-paragraph was amended by the law as of November 10, 2017/

21.6.Health insurance fund expenditure reports shall be audited and made conclusions in accordance with the Law on State Audit.

Article 22.Health insurance database and electronic card of the insured

22.1.The health insurance organization shall have an integrated electronic database on the registration and information of the insured, premium payments, and the payment of the expenses of the health care and service provided to the insured /hereinafter referred to as "electronic database"/, and the Government shall approve the rules of the electronic database.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

22.2.The electronic database shall contain information in regards with the income, expenditure, and activities of the health insurance fund, and create conditions to conduct  monitoring, analysis, evaluation, and forecasting in the health insurance fund's activities.

22.3.The electronic database shall contain information in regards with the list, location and hierarchy of health care and service provider organizations selected by the health insurance organization, as well as the number and quality assurance of health care and services being provided by them.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

22.4.The health insurance organization shall issue an electronic card to the insured to certify that he/she is covered under health insurance.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

22.5.The electronic card specified in paragraph 22.4 of this Law shall be the means of information for the insured to obtain health care and services specified in Article 9 of this Law, and to make payments by the health insurance organization to the health care and service provider organizations.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

22.6.The Government shall approve the design of the electronic card, the information to be stored in the electronic card, and the procedure for using the electronic card based on the proposal of the National Council.

CHAPTER SEVEN

CONTROL AND LIABILITY OF HEALTH INSURANCE ACTIVITIES

Article 23.Health care, service quality and payment control

23.1.The health insurance organization shall have a unit in charge of health care, service quality and payment control activities.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

23.2.The unit specified in paragraph 23.1 of this Law shall perform the following functions:

23.2.1.develop and implement plans and recommendations for continuous improvement of the quality of health care and services;

/This sub-paragraph was amended by the law as of December 17, 2021/

23.2.2.resolve applications, complaints, and suggestions made by the insured regarding health care, service quality and payment within the framework of relevant legislation, and protect the rights of the insured;

23.2.3.implement quality and payment control of health care and services in electronic and other forms in accordance with the procedures specified in sub-paragraph 14.8.7 of this Law;

/This sub-paragraph was added by the law as of August 28, 2020/

23.2.4.other functions provided by laws.

/The numbering of this sub-paragraph was amended by the law as of August 28, 2020/

23.3.When controlling the quality and payments of health care and services, and resolving the disputes, the health insurance organization shall cooperate with competent organizations authorized to conduct control and inspection, professional societies and associations, experts, insureds, participants, and partner parties.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

/This paragraph was amended by the law as of November 11, 2022/

Article 24.Control over the activities of the health insurance organization

24.1.The National Council shall discuss the activity report of the health insurance organization every year, and the financial report of the health insurance fund every quarter, and make a decision on relevant issues.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

24.2.The health insurance organization shall have an internal control unit, and the rules of the internal control unit shall be approved by the Social Insurance Organization.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

24.3.The activities of the health insurance organization shall be monitored by the state and external audit organizations and the state central administrative body in charge of health affairs.

/This paragraph was amended by the law as of July 21, 2016/

/This paragraph was amended by the law as of November 10, 2017/

/This paragraph was amended by the law as of November 11, 2022/

24.4.Citizens and legal entities may monitor the implementation of legislation on health insurance, demand the elimination of detected violations, and submit the matter to the competent authority for resolution.

Article 25.Liability to be imposed on the violators of the Law

25.1.If the actions of officials who violate this Law are not in criminal nature, they shall be held liable as provided in the Law on Civil Service.

25.2.Any person and legal entity who violates this Law shall be held liable as provided for in the Criminal code or the Law on Violations.

/This Article was modified by the law as of December 4, 2015/

Article 26.Regulating other health insurance relations

26.1.Relations other than those regulated by this Law regarding health insurance shall be governed by the provisions of the General Law on Social Insurance and other relevant laws.

/In this paragraph, the term "Law on Social Insurance" was amended into the term "General Law on Social Insurance" by the law as of July 7, 2023 and it shall enter into force on January 1, 2024/

CHAPTER EIGHT

MISCELLANEOUS

Article 27.Entry into force of the Law

25.1.This Law shall enter into force on July 1, 2015, and paragraph 8.1, sub-paragraph 8.2.4, and paragraph 15.1 of this Law shall enter into force on January 1, 2016, respectively.

THE CHAIRMAN OF THE STATE GREAT KHURAL OF MONGOLIA ENKHBOLD.Z