Key Terminology
統計名詞說明
Key Terminology
一、承保業務
● 投保單位 Group Insurance Applicants
全民健康保險法第十四條規定，各類被保險人之投保單位如下：
(一)第一類及第二類被保險人，以其服務機關、學校、事業、機構、雇主或所屬團體為投保單位。但國防部所屬被保險人之投保單位，由國防部指定。
(二)第三類被保險人，以其所屬或戶籍所在地之基層農會、水利會或漁會為投保單位。 (三)第四類被保險人：
1. 第八條第一項第四款第一目被保險人，以國防部指定之單位為投保單位。
2. 第八條第一項第四款第二目被保險人，以內政部指定之單位為投保單位。
(四)第五類及第六類被保險人，以其戶籍所在地之鄉(鎮、市、區)公所為投保單位。但安置於公私立社會福利服務機構之被保險人，得以該機構為投保單位。
Article 14
The group insurance applicants for the different Categories of the insured are as follows:
1. For the insured in Categories 1 and 2, the group insurance applicants shall be the agencies, schools, enterprises, institutions, or employers, which they work for, or unions where they hold membership. Nonetheless, the group insurance applicants that cover the insured in the Ministry of National Defense shall be designated by the Ministry of National Defense.
2. For the insured in Category 3, the group insurance applicants shall be the lowest-level Farmers Association, Irrigation Association or Fishers Association to which they belong, or located at the place where the insured have their household registered.
3. For the insured in Category 4, the group insurance applicants are as follows:
(1) For the insured in item 1, subparagraph 4, paragraph 1, article 8, the group insurance applicants shall be designated by the Ministry of National Defense.
(2) For the insured in item 2, subparagraph 4, paragraph 1, article 8, the group insurance applicants shall be designated by Ministry of the Interior.
4. For the insured in Categories 5 and 6, the group insurance applicants shall be the village (township, municipal, district) administration offices of their registered domicile; provided, however, the public or private social welfare service institutions may be the group insurance applicants for the insured who lives therein.
● 保險對象 Beneficiaries
保險對象分為被保險人及其眷屬：
(一)依據全民健康保險法第八條規定，被保險人分為下列六類： 1.第一類：
(1)政府機關、公私立學校之專任有給人員或公職人員。 (2)公、民營事業、機構之受雇者。
(3)前二目被保險人以外有一定雇主之受雇者。 (4)雇主或自營業主。
(5)專門職業及技術人員自行執業者。 2.第二類：
(1)無一定雇主或自營作業而參加職業工會者。
(2)參加海員總工會或船長公會為會員之外僱船員。 3.第三類：
(1)農會及水利會會員，或年滿十五歲以上實際從事農業工作者。
(2)無一定雇主或自營作業而參加漁會為甲類會員，或年滿十五歲以上實際從事漁業工作者。
4.第四類：
(1)應服役期及應召在營期間逾二個月之受徵集及召集在營服兵役義務者、國軍軍事學校軍費學生、經國防部認定之無依軍眷及在領卹期間之軍人遺族。
(2)服替代役期間之役齡男子。
5.第五類：合於社會救助法規定之低收入戶成員。
6.第六類：
(1) 榮民、榮民遺眷之家戶代表。
(2) 第一款至第五款及本款前目被保險人及其眷屬以外之家戶戶長或代表。
Article 8
The insured shall be classified into the following six categories :
1. Category 1
(1) Civil servants or full-time and regularly paid personnel in governmental agencies and public／private schools;
(2) Employees of publicly or privately owned enterprises or institutions;
(3) Employees other than the insured prescribed in the preceding two subparagraphs but are otherwise employed by particular employers;
(4) Employers or self-employed owners of business;
(5) Independently practicing professionals and technicians.
2. Category 2
(1) Members of an occupational union who have no particular employers, or who are self-employed;
(2) Seamen serving on foreign vessels, who are members of the National Seaman's Union or the Master Mariners Association.
3. Category 3
(1) Members of the Farmers Association or the Irrigation Association, or workers aged over fifteen who are actually engaged in agricultural activities;
(2) Class A members of the Fishers Association who are either self-employed or have no particular employers, or workers aged over fifteen who are actually engaged in fishery activities.
4. Category 4
(1) Military servicemen whose compulsory service terms are over two months or who are summoned to serve in military for more than two months, military school students who receive grants from the government, military servicemen’s dependents who lost their support recognized by the Ministry of National Defense, and military decedent’s families who are receiving pensions due to the death of their decedents;
(2) Men at the age for enlisting in the military, who are currently in military-substitute service.
5. Category 5
Members of a household of low-income families as defined by Social Support Law.
6. Category 6
(1) Veterans, household representatives of survivors of veterans;
(2) Representatives or heads of household other than the insured or their dependents prescribed in subparagraphs 1 to 5 and the preceding item of this subparagraph.
(二)依據全民健康保險法第九條規定，第一類至第三類及第六類被保險人之眷屬，規定如下：
1.被保險人之配偶，且無職業者。
2.被保險人之直系血親尊親屬，且無職業者。
3.被保險人二親等內直系血親卑親屬未滿二十歲且無職業，或年滿二十歲無謀生能力或仍在學就讀且無職業者。
Article 9
The dependents of the insured in Categories 1 to 3, and 6 are prescribed as follows:
1. The insured’s spouse who is not employed.
2. The insured’s lineal blood ascendants who are not employed.
3. The insured’s lineal blood descendants within second degree of relationship who are either under twenty years of age and not employed, or are over twenty years of age but incapable of making a living, including those who are in school without employment.
● 投保金額 Payroll-related premium Base
1.第一類至第三類被保險人之投保金額，由主管機關擬訂分級表，報請行政院核定之。投保金額分級表之下限與中央勞工主管機關公布之基本工資相同；基本工資調整時，該下限亦調整之。投保金額分級表最高一級投保金額與最低一級投保金額應維持五倍以上之差距，該表並應自基本工資調整之次月調整之。適用最高一級投保金額之被保險人，其人數超過被保險人總人數之百分之三，並持續十二個月時，主管機關應自次月調整投保金額分級表，加高其等級。
Article 21
The insured payroll-related amount for the insured in Categories 1 to 3 shall be subject to a grading table drafted by the Competent Authority and be reported to the Executive Yuan for approval.
The minimum in the said Grading Table of insured payroll-related amount shall be equal to the base salary promulgated by the central competent authority in charge of labor affairs. Upon adjustment of the base salary, such minimum shall be adjusted accordingly.
The insured payroll-related amount of the top level of the Grading Table of insured pay-roll related amount has to be kept fivefold higher than the amount in the bottom level, and the said Grading Table has to be revised in one month after the basic salary is adjusted. In case that the number of the insured applicable to the highest level of insured payroll-related amount exceeds three percent of the total number of the insured for twelve consecutive months, the Competent Authority shall readjust the Grading Table of insured payroll-related amount to advance another highest level starting from the following month.
2.第一類及第二類被保險人之投保金額，依下列各款定之： (1)受雇者：以其薪資所得為投保金額。
(2)雇主及自營作業者：以其營利所得為投保金額。
(3)專門職業及技術人員自行執業者：以其執行業務所得為投保金額。
第一類及第二類被保險人為無固定所得者，其投保金額，由該被保險人依投保金額分級表所定數額自行申報，並由保險人查核；如申報不實，保險人得逕予調整。
Article 22
The insured payroll-related amount for the insured in Categories 1 and 2 is determined on the following basis:
1. Employees: the payroll;
2. Employers and self-employed: the business income;
3. Independently practicing professionals and technicians: the income from professional practice.
If the insured prescribed in Categories 1 and 2, has no stable income, the insured shall select the proper insured payroll-related amount from the Grading Table of insured payroll-related amount and such insured payroll-related amount shall be examined by the Insurer, who may make adjustment at its own discretion if the insured payroll-related amount is found inappropriate.
3.第三類被保險人之投保金額，以第八條第一項第一款第二目、第三目及第二款所定被保險人之帄均投保金額計算之。但保險人得視該類被保險人及其眷屬之經濟能力，調整投保金額等級。
Article 23
The insured payroll-related amount applicable to the insured in Category 3 shall be the average amount for those specified under items 2, 3 of subparagraph 1, and subparagraph 2 of paragraph 1, Article 8; provided, that the Insurer may adjust the level of insured payroll-related amount according to the financial viability of the insured and their dependents.
4.第四類及第五類被保險人之保險費，以精算結果之全體保險對象每人帄均保險費計
算之。
Article 25
The premium of the insured in Categories 4 and 5 shall be calculated according to the averaged actuarial premium based on the total number of the beneficiaries.
5.第六類保險對象之保險費，以精算結果之全體保險對象每人帄均保險費計算之。眷屬之保險費，由被保險人繳納；超過三口者，以三口計。
Article 26
The premium of the beneficiaries in Category 6 shall be the average premium of all beneficiaries according to the actuarial results.
The premium of the dependents shall be paid by the insured. When the number of the dependents exceeds 3, the payment shall be calculated on the basis of only three dependents.
● 帄均投保金額 Average Payroll-related Premium Base
被保險人投保金額帄均數。
（各類投保金額×該類被保險人數）之合計
被保險人數
The average payroll-related premium base for insured:
Total of (amount for different types of premium base × number of insured under each category)
Number of insured
● 保險費負擔比率NHI Premium Contribution Proportions
全民健康保險保險對象共分六類，而各類保險對象之被保險人、投保單位、政府三者負擔或補助的保險費比率皆有所不同（詳附表）。
保 險 對 象 類 別 | 負 擔 比 率 （％） | ||||
被保險人 | 投保單位 | 政府 | |||
第 1 類第第 | 公務人員、志願役軍人 公職人員 | 本人及 眷 屬 | 30 | 70 | 0 |
私立學校教職員 | 本人及眷 屬 | 30 | 35 | 35 | |
公民營事業、機構等有一 定雇主的受雇者 | 本人及 眷 屬 | 30 | 60 | 10 | |
保 險 對 象 類 別 | 負 擔 比 率 （％） | ||||
被保險人 | 投保單位 | 政府 | |||
第 1 類 | 雇主 自營作業者 專門職業及技術人員自行執業者 | 本人及眷 屬 | 100 | 0 | 0 |
第 2 類 | 職業工會會員 外僱船員 | 本人及 眷 屬 | 60 | 0 | 40 |
第 3 類 | 農民、漁民、農田水利會 會員 | 本人及 眷 屬 | 30 | 0 | 70 |
第 4 類 | 義務役役男、軍校學生、無依軍眷、在卹遺族、替代役役男 | 本 人 | 0 | 0 | 100 |
第 5 類 | 低收入戶 | 本 人 | 0 | 0 | 100 |
第 6 類 | 榮民、榮民遺眷 | 本 人 | 0 | 0 | 100 |
眷 屬 | 30 | 0 | 70 | ||
地區人口 | 本人及眷 屬 | 60 | 0 | 40 | |
全民健康保險之保險費因投保金額、保險費率、負擔或補助比率之不同而有差異，其計算公式分別如下：
1. 被保險人及其眷屬負擔部分：
(1)第 1 類至第 3 類被保險人及其眷屬：
投保金額×保險費率×負擔比率×（1+眷屬人數） (2)第 6 類第 1 目之榮民眷屬：
帄均保險費×負擔比率×眷屬人數 (3)第 6 類第 2 目其他地區人口：
帄均保險費×負擔比率×（1+眷屬人數）
2. 投保單位負擔部分：
投保金額×保險費率×負擔比率×（1+帄均眷口數）
3. 政府補助部分：
(1)第 1 類至第 3 類保險對象：
投保金額×保險費率×負擔比率×（1+帄均眷口數） (2)第 4、5 類保險對象：
帄均保險費×負擔比率×實際投保人數 (3)第 6 類保險對象：
帄均保險費×負擔比率×（1+眷屬人數）
以上眷屬部分採論口計費，且超過 3 口者以 3 口計算。帄均眷口數則以第 1 類至第 3
類被保險人實際眷屬人數帄均計算，目前帄均眷口數為 0.7 人（96 年 1 月調整）。
The beneficiaries under the National Health Insurance scheme are divided into six categories and the premium contribution rates to be borne or subsidized by the insured, the group insurance applicant, and the government vary depending on the category of beneficiaries (see table below).
Category of Beneficiaries | Percentage (％) | ||||
The Insured | Group Insurance Applicants | Government | |||
Category 1 | Civil Servants, Voluntary Military Personnel, Government Employees | The Insured and Dependents | 30 | 70 | 0 |
Private School Faculty and Staff | The Insured and Dependents | 30 | 35 | 35 | |
Employees with Specific Employers in Public or Private Enterprises or Institutions | The Insured and Dependents | 30 | 60 | 10 | |
Employers Self-employed Business Owners Independently Practicing Professionals and Technicians | The Insured and Dependents | 100 | 0 | 0 | |
Category 2 | Occupational union Members Without Specific Employers Alien Seamen | The Insured and Dependents | 60 | 0 | 40 |
Category 3 | Farmer, Fisherman, and Members of Irrigation Associations | The Insured and Dependents | 30 | 0 | 70 |
Category 4 | Conscription Draftees, Military School Students, Bereaved Dependent(s) of Deceased Serviceman, Substitute Civilian Serviceman | The Insured | 0 | 0 | 100 |
Category of Beneficiaries | Percentage (％) | ||||
The Insured | Group Insurance Applicants | Government | |||
Category 5 | Low-income Household | The Insured | 0 | 0 | 100 |
Category 6 | Veterans, Household Representatives of Survivors of Veterans | The Insured | 0 | 0 | 100 |
Dependents | 30 | 0 | 70 | ||
Other District-level Residents | The Insured and Dependents | 60 | 0 | 40 | |
National Health Insurance charges different levels of premium based on insured payroll-related amount, premium rate, and contribution or subsidy percentage. The formulae are shown below.
1. Contribution from the insured and dependents:
(1) The insured and dependents in Categories 1 to 3:
Insured payroll-related amount × Premium rate × Contribution rate × (1 + Number of dependents)
(2) Veteran’s surviving dependents in Item 1 of Category 6:
Average premium × Contribution rate × Number of dependents
(3) District-level residents in Item 2 of Category 6:
Average premium × Contribution rate × (1 + Number of dependents)
2. Contribution from group insurance applicants:
Insured payroll-related amount × Premium rate × Contribution rate × (1 + Average number of dependents)
3. Contribution from government subsidies:
(1) The beneficiaries in Categories 1 to 3:
Insured payroll-related amount × Premium rate × Contribution rate × (1 + Average number of dependents)
(2) The insured in Categories 4 and 5:
Average Premium × Contribution rate × Actual number of the insured
(3) The beneficiaries in Category 6:
Average Premium × Contribution rate × (1 + Number of dependents)
When the number of the dependents exceeds 3, the payment shall be calculated on the basis of only
three dependents. The number of dependents in Categories 1 to 3 shall be the average number of the dependents that the insured in Category 1 to 3 actually have. The current average number of dependents is 0.7 person (adjusted in January 2007).
二、財務狀況
● 應收保險費 Premium Receivable
為當月(年)計費產生之保險費金額。
This is the amount of premium that is receivable upon each month (year)
● 實收保險費 Premium Collected
為當月(年)實際收到開單之保險費。
This is the premium that is received with receipt upon each month (year).
● 收繳率 Collection Rate
實收保險費應收保險費
×100 %
Premium Collected Premium Receivable
×100 %
● 資本 Capital
由中央政府撥付中央健康保險局辦理全民健康保險所需之設備費用及週轉金。
This is the equipment fees and revolving funds needed for NHI received by the Bureau of National Health Insurance, Department of Health from the Central Government.
● 代辦醫療費用收入 Income from Medical Service Provision
政府機關委託中央健康保險局代辦醫療給付之補助款。其代辦項目為榮民及榮民遺眷家戶代表醫療費用之自行負擔、低收入戶醫療費用之自行負擔、結核病患者醫療費用之自行負擔、慢性開放性結核病患住院醫療之病房費及診察費、山地鄉結核病患者住院醫療之病房費及診察費、康復之家住宿費、低收入戶住院膳食費、法定傳染病之醫療費用、職業傷病之醫療費用、職業傷病之住院膳食費、職業傷病之預防健檢等。
This is the subsidy given from government authority to the Bureau of National Health Insurance, Department of Health for providing medical service. The medical service provided by the Bureau of National Health Insurance are: self-paid medical expenses for veterans, household representatives of
survivors of veterans; self-paid medical expenses for low-income citizens, patients with tuberculosis; and self-paid medical expenses for treatments; the ward fees and diagnosis fees for patients with open tuberculosis and those patients who live in remote areas with open tuberculosis; the fees for staying in recovery home; the hospital fees for low-income patients; the treatment fees for notifiable infectious disease; treatment fees and hospital fees for occupational injury and disease; prevention and checkup of occupational injury and disease.
● 滯納金 Delinquency Charges
投保單位或被保險人逾期繳納保險費者，每逾一日，將另加徵其應納費額百分之零點一滯納金，但加徵之滯納金額以至應納費額之百分之十五為限，但一定金額以下之小額滯納金得予免徵，其數額由主管機關定之。
The delinquency charges shall be calculated as 0.1% of the amount that should be paid for every one day delayed for the insured unit and the insured. However, the maximum rate to be charged as delinquency charges is 15%, and small delinquency charges do not have to be paid under a certain amount, and must be determined by the authority.
● 滯納金收回筆數百分比 Percentage Collected by Number
收回筆數
滯納筆數 × 100 %
● 滯納金收回金額百分比 Percentage Collected
收回金額
滯納金額 × 100 %
● 安全準備 Reserve Fund
為帄衡保險財務，應提列安全準備，其來源如下：
1.由每年度保險費收入總額百分之五範圍內提撥；其提撥率，由主管機關定之。
2.年度收支之結餘。
3.保險費滯納金。
4.安全準備所運用之收益。
年度收支發生短絀時，應由安全準備先行填補。
Article 63
In order to balance the insurance finances, this Insurance shall set aside a reserve fund from the following sources:
1. Proportion stipulated by the Competent Authority within 5 percent of the total premium revenues of each fiscal year;
2. Surplus from each fiscal year;
3. Premium overdue charges;
4. Profits generated from the management of the reserve fund.
Deficiency in the balance of insurance revenue and expenditure of each fiscal year shall be recovered by the reserve fund first.
● 菸酒健康福利捐分配收入 Added Social Health Insurance Contributions for Alcohol and Tobacco
依全民健康保險法第六十四條規定，政府得開徵菸酒健康福利捐，將其收入之一定比例提列為本保險安全準備。
Article 64
The government may impose the social health and welfare surcharge on tobacco and alcoholic products and deposit a proportion of the surcharge collected therefrom in the reserve fund.
Notwithstanding the relevant provisions of the Act Governing the Allocation of Government Revenues and Expenditures, the implementation regulations for setting aside a proportion of the social health and welfare surcharge as the reserve fund shall be jointly promulgated by the Competent Authority and the central competent authority in charge of finance.
● 公益彩券分配收入 Social Welfare Lottery Income
依全民健康保險法第六十五條規定，政府應提撥社會福利彩券收益之一定比例，提列為本保險安全準備。
Article 65
The government shall set aside a certain proportion of returns from social welfare lottery as the reserve fund.
The implementation regulation for the preceding paragraph shall be jointly established by the Competent Authority and the central competent authority in charge of finance and shall not be subject to the limitations of the relevant provisions of the Government Fiscal Revenues and Expenditures Allocation Law.
● 醫療費用 Medical Expenditure
凡依全民健康保險法承保之各類保險所發生之保險醫療給付及成本屬之。
Medical benefit payments and costs incurred from types of insurance under the National Health Insurance Act.
● 保險成本 Insurance Cost
凡本局保險業務所發生之保險給付(醫療費用)、利息費用、各項提存(提存呆帳等)、買賣票券損失、其他有關之各項費用等屬之。
Insurance payments (medical expenses), interest fees, all types of lodge payments (delinquent accounts, etc), the loss brought by the trading of bills incurred from the NHI’s insurance administration.
● 支付醫療費用 Advances on Medical Expenses
指保險費收入不足支應醫療費用時，先行以安全準備墊付之款項。
This refers to the advances that are used to pay for medical expenses when the insurance income is not enough to pay for medical expenses.
● 彌補虧損 Coverage of Losses
指當年度收支發生短絀時，由安全準備先行填補之數。
This refers to the amount that is prepared in advance for coverage purposes in case of the shortage reflected in the annual statement.
● 特約醫院建物整修及擴建之貸款 Loans to Contracted Hospitals for Construction and Expansion
為全民健康保險資金運用方式之一。
This is one way of utilizing the capitals for NHI.
三、醫事服務機構特約及管理
● 醫療院所特約類別 Hospital by Contracted Category.
醫學中心 Academic Medical Centers
包含評鑑別中之醫學中心、準醫學中心、新制醫院評鑑特優且新制教學醫院評鑑優等(評鑑年度申請「醫學中心給付」排序於給付家數上限以內之醫院)。
This includes the medical center, would-be medical centers under accreditation, those centers that are evaluated as outstanding in the “New System Hospital Accreditation Scheme”, and as excellent in the “New Teaching Hospital Accreditation” (hospital that is within the maximum number of applicants when applying for the “payment for hospital centers” under annual accreditation scheme).
區域醫院 Metropolitan Hospitals
包含評鑑別中之區域醫院、準區域醫院、特殊功能教學醫院、精神專科教學醫院、新制醫院評鑑特優或新制醫院評鑑優等或新制醫院評鑑合格(評鑑年度申請「區域醫院給付」排序於給付家數上限以內之醫院)、新制精神科醫院評鑑優等且精神科教學醫院評鑑合格、新制精神科醫院評鑑合格且精神科教學醫院評鑑合格。
These include the metropolitan hospitals, would-be metropolitan hospitals, Specific Function Teaching Hospitals, Mental Teaching Hospitals; and those hospitals that rate as outstanding, excellent, or qualified in the “New System Hospital Accreditation Scheme” (hospital that is within the maximum number of applicants when applying for the “payment for hospital centers” under annual accreditation scheme); those hospitals that are rated as excellent and qualified in the “New Psychiatric Hospital Accreditation”, and as qualified in both “New Psychiatric Hospital Accreditation” and “New Hospital Accreditation of Psychiatry”.
地區醫院 Local Community Hospitals
包含評鑑別中之地區教學醫院、地區醫院、精神專科醫院、地區醫院（合格一年、暫准合格）、精神專科醫院（合格一年、暫准合格）、部分非評鑑不合格西醫醫院專案認定比照地區醫院、新制醫院評鑑特優或新制醫院評鑑優等或新制醫院評鑑合格(評鑑年度未申請「醫學中心給付」或「區域醫院給付」之醫院)、新制精神科醫院評鑑優等、新制精神科醫院評鑑合格。
These include the local teaching hospitals, local community hospitals, psychiatry hospital, local community hospital (qualified for one year or pending status in qualification), psychiatry hospital (qualified for one year or pending status in qualification) under the accreditation scheme; some of the western hospital projects that are not disqualified by the accreditation scheme, and shall be considered as qualified following the example of local community hospital, or hospitals that are considered as outstanding in the “New System Hospital Accreditation Scheme” or rated as qualified in the “New System Hospital Accreditation Scheme” (hospitals that did not apply for “medical center payment” or “local community hospital payment” in the accreditation scheme); and rated as outstanding and qualified in the “New Hospital Accreditation of Psychiatry.”
基層院所 Physician Clinics and Dental Clinics
包含評鑑別中之西醫醫院（非評鑑、不合格）、中醫醫院（非評鑑、不合格）、基層診所／其他。
These include the western hospitals (non-accreditation based, disqualified), Chinese hospitals (non-accreditation based, disqualified), office-based clinics/others.
藥局 Pharmacies
指合格藥師或藥劑生親自主持開設，依法執行藥品調劑、供應業務之處所。
The business operating unit that dispenses and provides medicine in accordance to laws and is the unit is operated by a qualified physician or a pharmacist.
● 保險病床 Insured Beds
指特約醫院提供保險對象住院診療未收取病床費差額之病床。
Beds that are provided by contracted hospitals to the insured without collecting the fees needed for the balance billing.
● 保險病床比率 The Proportion of Insured Beds
依全民健康保險醫事服務機構特約及管理辦法第三十七條之規定計算。
特約醫療院所保險總病床數特約醫療院所總病床數
× 100 %
This is calculated in accordance to Article 37 of the Regulations of Administration on NHI contracting
Health Care Institutes.
total number of insured beds in the contracting hospital total number of beds in the contracting hospital
× 100 %
● 急性保險病床比率 The Proportion of Insured Acute Beds
特約醫療院所急性保險病床數－急診處暫留床－洗腎治療床－嬰兒床特約醫療院所急性總病床數－急診處暫留床－洗腎治療床－嬰兒床
● 慢性保險病床比率 The Proportion of Insured Chronic Beds
× 100 %
特約醫療院所慢性保險病床數特約醫療院所慢性總病床數
● 扣減費用 Penalities
× 100 %
依全民健康保險醫事服務機構特約及管理辦法第六十五條規定，保險醫事服務機構有下列情事之一者，保險人應扣減其醫療費用之十倍金額：
(1)未依處方箋或病歷記載提供醫療服務。 (2)未經醫師診斷逕行提供醫療服務。
(3)處方箋之處方或醫療費用申報內容與病歷記載不符。 (4)未記載病歷，申報醫療費用。
(5)除第六十七條第一項第四款至第十一款所定情事外，有容留人員違反醫事人員法令，擅自執行應由特定醫事人員執行之醫療業務，且該人員經衛生主管機關處分或經判刑確定。
前項應扣減之之醫療費用，保險人得於保險醫事服務機構應領之醫療費用中逕行抵扣。 In accordance to Article 65 of Regulations of Administration on NHI contracting Health Care Institutes, if any of the following occurs within the health care institute that provides medical insurance, 10 times of the amount of the medical expenses of the insured shall be deducted as penalty:
(1) The medical services were not provided according to prescriptions or medical records.
(2) The medical services were not provided according to the doctor’s diagnosis.
(3) The content of the prescription or the medical expenses do not correspond to those on the medical records.
(4) The application for the reimbursement of medical expenses without medical records.
(5) Except for circumstances described in Article 67.1.4 to Article 67.1.11, the institution still keeps the medical staff who has violated acts regulating the medical professionals, or provided medical services that can only be provided by specific medical professionals, and such medical staff has also
been subject to penalty or a sentence by a health authority as their employee.
The insured shall claim the amount of medical expenses that should be deducted mentioned in the previous paragraph from the reimbursement provided by the medical institution with health insurance.
● 違約記點 Corrections
依全民健康保險醫事服務機構特約及管理辦法第六十四條規定，保險醫事服務機構，有下列情事之一者，保險人應予違約記點：
(1)未依醫療法或本保險相關法規辦理轉診業務。
(2)違反第十條至第十四條、第二十九條、第三十一條、第三十六條第二項、第三十七條或第三十九條規定。
(3)未依本保險醫療辦法規定，核對保險對象就醫文件。
(4)保險對象因分娩、緊急傷病就醫未及攜帶保險憑證，經自費就醫後，於七日內補送保險憑證時，未依本保險醫療辦法規定，將所收之保險醫療費用退還，且於保險憑證上補行登錄。
(5)未依本保險醫療辦法規定，辦理保險對象之住院及住院期間之請假、離院。
(6)未依本法之規定向保險對象收取其應自行負擔之費用。
(7)其他經保險人通知應限期改善而未改善者。
In accordance to Article 64 of Regulations of Administration on NHI contracting Health Care Institutes, if any of the following occurs within the health care institute that provides medical insurance, the insured shall apply for corrections:
(1) The transfer of medical service provision to another without complying with relevant medical regulations and this Act.
(2) The act of violation to Articles 10 to 14, Article 29, Article 31, Article 36.2, Article 37 or Article 39.
(3) The examination to check the medical documents of the insured that did not comply with the regulations under this Act.
(4) Those insured who did not carry the IC card due to childbirth and emergency and received medical treatment by self-payment, and have submitted the IC card within 7 days without complying with the regulations under this Act and received the reimbursement while making registration record afterwards on the IC card.
(5) The administration of the procedure concerning the insured’s application for leave, leaving the hospital while staying in the hospital that did not comply with this Act.
(6) The collection of fees that shall be paid by the insured without complying with this Act.
(7) Any corrections that shall be made upon informed by the insured that did not occur within a time limit.
● 停止特約 Suspension of Contract
依全民健康保險醫事服務機構特約及管理辦法第六十六條規定，保險醫事服務機構於特約期間有下列情事之一者，保險人應予停止特約一至三個月，或就其違反規定部分之診療科別或服務項目停止特約一至三個月：
(1) 違反本法第五十八條、第六十二條規定，經保險人分別處罰三次後再有違反。
(2) 依第六十四條規定受違約記點三次後，再有同條規定情事之一。
(3) 經扣減醫療費用三次後，再有前條規定情事之一。
(4) 不當招攬病人，經衛生主管機關處分。
(5) 收治非保險對象，而以保險對象之名義，申報醫療費用。
(6) 登錄保險對象保險憑證，換給非對症之藥品、營養品或其他物品。
(7) 拒絕對保險象提供適當醫療服務，且情節重大。
(8) 未診治保險對象，卻自創就醫紀錄，虛報醫療費用。
(9) 其他以不正當行為或以虛偽之証明、報告或xx，申報醫療費用。
In accordance to Article 66 of Regulations of Administration on NHI contracting Health Care Institutes, if one of the following occurs during the contracting period within the health care institute that provides medical insurance, the medical service under contract, or the type of treatment or service that is in violation to the Act provided to the insured shall be suspended from 1 to 3 months:
(1) A second violation to Article 58 and 62 after being penalized by the insured on three separate accounts to each of the Article.
(2) A second occurrence of the circumstances described under Article 64 after being recorded three demerits for violation of the Article.
(3) A second occurrence of the circumstances described in (2) of this paragraph after a third deduction of medical expenses.
(4) Subject to the penalty by health authority for inappropriate solicitation of patients.
(5) The acceptance and treatment of uninsured in the name of the insured to claim for medical reimbursement.
(6) Register in the medical record database with the insured’s IC card for providing medications, health products and other articles that do not correspond to the symptoms of the patients.
(7) The refusal to provide adequate medical services to the insured and causing a serious and adverse effect with such action.
(8) The making of false medical record when there has not been such treatment of an insured to claim medical expenses.
(9) Using inappropriate ways or false evidence, report, or account to claim for medical expenses.
● 終止特約 Termination of Contract
依全民健康保險醫事服務機構特約及管理辦法第六十七條規定，保險醫事服務機構有下列情事之一者，應予終止特約，或就特約醫院違反規定部分之診療科別或服務項目停止特約一年：
(1) 保險醫事服務機構或其負責醫事人員依前條規定受停止特約，經執行完畢後二年內再有前條規定情事之一。
(2) 以不正當行為或以虛偽之證明、報告或xx，申報醫療費用，其情節重大。
(3) 因違反醫療管理相關法規，經衛生主管機關廢止開業執照處分。
(4) 特約醫院及診所容留未具醫師資格之人員為保險對象診療或處方。
(5) 特約藥局容留未具藥事人員資格之人員為保險對象調劑。
(6) 特約醫事檢驗所容留未具醫事檢驗人員資格之人員為保險對象檢驗。
(7) 特約醫事放射所容留未具醫事放射人員資格之人員為保險對象施行放射業務。
(8) 特約居家護理機構容留未具護理人員資格之人員擅自執行護理業務。
(9) 特約助產機構容留未具助產人員資格之人員為保險對象提供助產服務。
(10) 特約物理治療所容留未具物理治療人員資格之人員為保險對象提供物理治療服務。
(11) 特約職能治療所容留未具職能治療人員資格之人員為保險對象提供職能治療服務。
(12) 依前條規定受停止特約期間，仍繼續於保險對象保險憑證上登錄，並以不實之就診日期申報醫療費用，或交由其他保險醫事服務機構申報。
(13) 依第一款至第十二款規定，受終止特約或停止特約一年，期滿再申請特約後，經查於終止特約或停止特約一年期間，仍繼續於保險對象保險憑證上登錄，並以不實之就診日期申報醫療費用，或交由其他保險醫事服務機構申報。
保險醫事服務機構因歇業註銷其開業執照者，應予終止特約。
依第一項規定受終止特約者，自終止之日起一年內，不得申請特約。
In accordance to Article 67 of Regulations of Administration on NHI contracting Health Care Institutes, if one of the following occurs within the health care institute that provides medical insurance, the medical service under contract, or the type of treatment or service that is in violation to the Act provided to the insured shall be suspended for 1 year:
(1) There has been a second occurrence of the circumstances described in the previous paragraph within two years after the termination of contract of any health care institute that provides medical insurance, or those medical staffs who are responsible for administration.
(2) Using inappropriate ways or false evidence, report, or account to claim for medical expenses.
(3) Subject to the abolishment of license to practice by health authority as penalty resulting from violation of regulations on medical care.
(4) Contracting hospitals and clinics that keep those without doctor’s qualification to provide treatment or prescriptions to the insured.
(5) Contracting pharmacies that keep those without pharmacist’s qualification to dispense of medicines.
(6) Contracting medical laboratory institutions that keep those without medical examination
qualifications to perform medical examinations for the insured.
(7) Contracting medical radiology centers that keep those without radiologist qualifications to perform operations related to radiology.
(8) Contracting home nursing cares that keep those without home care qualifications to perform operations related to home care.
(9) Contracting midwifery clinics that keep those without postpartum nursing care qualifications to perform operations related to postpartum nursing care.
(10) Contracting physical therapy clinics that keep those without physical therapy qualifications to perform operations related to physical therapy.
(11) Contracting occupational therapy clinics that keep those without occupational therapy qualifications to perform operations related to occupational therapy.
(12) Using the IC card of those insured to register medical records and report a false diagnosis to claim medical expenses, or allowing other medical institutions that provide insurance to claim medical expenses during the period of termination of contract as a result of the circumstances described in the previous paragraphs.
(13) Upon examination, there has been an account of using the IC card of those insured during the time that contract was terminated or the one year that the contract was terminated after re-application for such contract according to regulations from Article 1 to Article 12, and claim for medical expenses using false report of treatment date, or allowing other medical institutions that provide insurance to claim medical expenses.
Contracts shall be terminated for those medical institutions that provide insurance and have been subject to the nullification of license due to suspension of services.
Those whose contracts are terminated pursuant to (1) of this paragraph shall not apply for contract again within one year after the termination.
● 重大傷病 Major Illness/Injury
指行政院衛生署公告之「全民健康保險重大傷病範圍」所列各項傷病。
This refers to the types of injury and disease listed under the “Scope of Major Illness under National Health Insurance” announced by the Department of Health, Executive Yuan.
四、醫療給付
● 門診件數 Outpatient Cases
全年內前往特約醫事機構經掛號後，實際赴門診就醫之件數，並含急診件數。
The number of outpatient cases after registration in contracted medical institutions, including the
emergency cases.
● 住院件數 Inpatient Cases
全年住院費用之件數，住院期間醫療院所分數次申報費用，每一次算一件。
The number of impatient cases, in which the fees will be declared on separate accounts, and one declaration shall be counted as one application.
● 申報點數 Claims
費用發生年月之申報點數。
The medical benefit claims for RVU that is being claimed on such year or month.
● 核付金額(點數) Approved Benefit Payments
費用發生年月之核付金額(點數)。
The payment (RVU) that is granted in accordance to the fee incurred on such year or month after the initial verification.
● 自行負擔金額 Copayment
全年內保險對象至特約醫事機構就診自行負擔之醫療費用。
The annual medical expenses born by the insured when visiting contracted medical institution for treatment.
● 住院日數 Inpatient Days
依申報規定以保險對象入院之日起計，包括佔急性病床日數和慢性病床日數，出院當日不計。
This refers to the days starting from the day that the insured is checked into the hospital, including the days occupying the emergency beds and chronic until the day that is checked out of the hospital (but this day is not counted).
● 帄均每件點數 Average RVU Per Case.
(申報、核付)費用點數／(申報、核付)件數。
The points for the application of NHI/ number of cases.
● 帄均每日點數 Average RVU Per Day
住院(申報、核付)費用點數／總住院(申報、核付)日數。
The point for the application of staying in the hospital/total days in the hospital.
● 帄均每件住院日數 Average Length of Stay.
總住院(申報、核付)日數／住院(申報、核付)件數。
Total days in the hospital/the number of applications for staying in the hospital.
● 自墊醫療費用 Cash Reimbursement of Medical Expense for Out-of-Plan Services
緊急傷病
保險對象有下列情形之一者，得申請核退醫療費用：
1.全民健康保險施行區域內，因緊急傷病不克前往本保險醫事服務機構就醫，必須於附近非保險醫事服務機構急救者。
2.全民健康保險施行區域內，因情況緊急不克前往本保險醫事服務機構分娩，必須於非保險醫事服務機構分娩，或延請合格醫師或助產士接生者。
3.全民健康保險施行區域外（包括國外及大陸地區）發生不可預期之傷病或緊急分娩，必須於當地醫療機構就醫或分娩者。
Emergency
If one of the following occurs, the insured can apply for the reimbursement of medical expenses:
1. Those who cannot reach the medical institution that provides NHI within the region that accepts NHI during emergency, and have to go to the medical institution that does not accept NHI.
2. Those who cannot reach the medical institution that provides NHI within the region that accepts NHI during emergency, and have to go to the medical institution that does not accept NHI for childbirth, or had to have a qualified doctor or midwife.
3. Those who have been exposed to unexpected harm or emergency childbirth in regions that are outside the areas that accept NHI (including foreign countries and China) and had to seek treatment or give birth in local medical institutions.
特殊情況
保險對象因特殊情況符合下列情形之一，於保險醫事服務機構自墊醫療費用就醫者，得申請核退醫療費用：
1.未依全民健康保險法(以下簡稱本法)規定投保，而依本法第六十九條之一規定處以罰鍰及暫不予保險給付，於暫不予保險給付期間，在保險醫事服務機構自墊醫療費用就醫，並已繳清罰鍰及保險費者。
2.依本法第三十條第三項規定，經暫行拒絕保險給付，於暫行拒絕保險給付期間，在保險醫事服務機構自墊醫療費用就醫，並已繳清保險費及滯納金者。
3.未依本法第三十三條及第三十五條規定繳納應自行負擔之費用，經暫行拒絕保險給付，於暫行拒絕保險給付期間，在保險醫事服務機構自墊醫療費用就醫，並已繳清其應自行負擔之費用者。
4.符合全民健康保險醫療辦法第六條規定，未及於就醫日起七日內向保險醫事服務構補送保險憑證者。
5.依本法第三十五條第二項及其施行細則第六十四條第三項規定，每年應自行負擔之住院費用，超過最近一年每人帄均國民所得之百分之十者。
6.符合本法第三十六條重大傷病者，於住院期間死亡或因不可歸責因素，未及於住院期間提出申請，並已付該次住院部分負擔費用者。
Special circumstances
Those insured with one of the following circumstances who had to pay for medical expenses in medical institutions that provide insurance can apply for reimbursement:
1. Those who did not enroll in the NHI which is required under the National Health Insurance Act (hereinafter referred as the Act), and being subject to penalty and suspension of insurance coverage under Article 69.1 of this Act, have sought treatment in medical institutions that provide insurance with self-payment and cleared the penalty and insurance premium during such period.
2. According to Article 30.3 of this Act, those who are subject to suspension of insurance coverage, and have sought treatment in medical institutions that provide insurance with self-payment and cleared the insurance premium and delinquency during such period.
3. According to Article 33 and Article 35 of this Act, those who did not pay for the medical expenses under self-payment and are subject to suspension of insurance coverage, and have sought treatment in medical institutions that provide insurance and cleared self-payment during such period.
4. Those insured who did not present their NHI card when seeking treatment in medical institutions that provide insurance and re-submitted their NHI card within seven days pursuant to Article 6 of National Health Insurance Act.
5. The amount of the medical expenses that those insured have to pay on their own according to Article
35.2 of this Act and Article 64.3 of the Enforcement Guidelines of this Act annually exceed 10% of the national income in the most recent year.
6. Those insured who died or have not made the application on time due to reasons beyond control during the stay in hospital and have cleared part of the medical expenses that the insured must pay on their own pursuant to Article 36 of this Act.
● 一般案件 General Cases
門診一般案件係指基層診所依藥費定額給付之案件，住院一般案件指非屬高額、特定及論病計酬案件者。
General cases refer to the cases that are being charged based on the price of prescriptions from office-based clinics. General cases of those staying in the hospital refer to cases that are not charged with a high price, specific or paid by case.
● 論病例計酬案件 Case-payment Cases
係依據全民健康保險醫療費用支付標準第七部所列國際疾病診斷碼及手術(或處置)碼並依其相關規定申報醫療費用之案件。
This refers to the application for reimbursement of medical expenses in accordance to the international
classification of diseases and the classification for operation (treatment) under Section 7 of the Payment Standard for National Health Insurance and the relevant regulations.
● 特定案件 Special Cases
保險醫事服務機構執行特定醫療服務並採逐案審查之案件。
The special cases executed in the medical institutions that provide insurance which require examinations on a case by case basis.
● 詴辦計畫 Pilot Project
尚未納入支付標準，由本局或各總額部門推動之醫療照護暫行計畫。
The project that has not been under the payment standard, and shall be planned and promoted by the public health bureau and the department of local and global budget payment system.
● 交付機構 Delivery Institutions
包括特約藥局、醫事檢驗所、醫事放射所、物理治療所、職能治療所及病理中心等機構。 These include contracted pharmacies, clinical laboratory, radiological laboratory, physical therapy laboratory, occupational therapy laboratory and institute of pathology.
● 住院安寧療護 Inpatient Hospice Care
安寧療護案件為符合全民健康保險醫療費用支付標準第二部第一章第八節規定申報之案件。
Inpatient hospice care cases refer to those specified under section 8, chapter 1, Part II of NHI Payment Standards for Medical Care.
●代辦案件 Commission cases
非屬全民健康保險給付範圍之委辦案件。
Commission cases refer to entrusted cases which are not covered in National Health Insurance.