Circular 22/2024/TT-BYT issued by the Minister of Health stipulates the direct payment of drug and medical equipment costs for insured individuals seeking medical treatment.

 CIRCULAR

Regulations on direct payment of drug and medical device costs for insured individuals seeking medical examination and treatment

person holding a health insurance card for medical examination and treatment

Pursuant to the Health Insurance Law dated November 14, 2008, amended and supplemented by the Health Insurance Law dated June 13, 2014;

Pursuant to Decree No. 146/2018/NĐ-CP dated October 17, 2018 of the Government detailing and guiding implementation methods for certain provisions of the Health Insurance Law; and Decree No. 75/2023/NĐ-CP dated October 19, 2023 of the Government amending and supplementing certain provisions of Decree No. 146/2018/NĐ-CP dated October 17, 2018 of the Government detailing and guiding implementation methods for certain provisions of the Health Insurance Law;

Pursuant to Decree No. 95/2022/NĐ-CP dated November 15, 2022 of the Government stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;

At the request of the Director of the Health Insurance Department,

The Minister of Health issues this Circular regulating direct payment of drug and medical device costs for insured individuals seeking medical examination and treatment.

Article 1. Scope of Regulation

This Circular regulates direct payment of drug and medical device costs within the scope of benefits for health insurance participants when seeking medical examination and treatment as stipulated at point c, Clause 2 and Clause 3, Article 31 of the Health Insurance Law at healthcare facilities that have signed contracts for health insurance medical examination and treatment services funded from the health insurance fund, including:

1. Cases where drugs and medical devices are covered for payment.

2. Payment conditions.

3. Payment levels.

4. Payment documentation and procedures.

Article 2. Cases where drugs and medical devices are covered for payment

1. Drugs included in the List of Rare Medicines issued together with Circular No. 26/2019/TT-BYT dated August 30, 2019 of the Minister of Health regarding the List of Rare Medicines.

2. Medical devices classified as type C or D, except for in vitro diagnostic medical devices, special personal medical devices, and medical devices listed in the medical device list promulgated by the Minister of Health according to the regulations on purchasing and selling such goods as ordinary commodities under Decree No. 98/2021/NĐ-CP dated November 8, 2021 of the Government on medical equipment management and Decree No. 07/2023/NĐ-CP dated March 3, 2023 of the Government amending and supplementing certain provisions of Decree No. 98/2021/NĐ-CP dated November 8, 2021 of the Government on medical equipment management.

Article 3. Payment Conditions

At the time of prescribing drugs or designating the use of medical devices, the following conditions must be met:

1. There are no drugs or medical devices currently undergoing tender selection according to approved tender plans through one of the following methods: open tender, limited tender, competitive bidding, direct purchase, special case tender selection, online bidding, or online procurement, and have implemented simplified tender designation according to point c, Clause 1, Clause 2, Article 23 of the Bidding Law and Clause 1, Article 94 of Decree No. 24/2024/NĐ-CP dated February 27, 2024 of the Government detailing certain provisions and implementing measures of the Bidding Law on tender selection but have not selected a contractor. Simultaneously, at the healthcare facility:

a) For drugs: There is no commercial drug containing the active ingredient prescribed for the patient or a different concentration, dosage form, or route of administration, and cannot be substituted for the prescription for the patient;

b) For medical devices: There is no medical device designated for the patient's use and there is no substitute medical device available.

2. Patients shall not be transferred to another healthcare facility in any of the following cases:

a) The patient's health condition or disease is determined to not meet the transfer criteria;

b) The healthcare facility where the patient is being examined and treated is under mandatory quarantine according to laws on infectious disease prevention and control;

c) The healthcare facility where the patient is being examined and treated is a specialized deep-level healthcare facility.

3. It is not possible to transfer drugs or medical devices between healthcare facilities according to the law.

4. Prescribed drugs and designated medical devices for use must be within the scope of expertise of the healthcare facility and have been paid for health insurance medical examination and treatment costs at one of the national healthcare facilities.

5. Prescribed drugs and designated medical devices for use must fall within the benefit scope of health insurance participants.

Article 4. Level of Direct Payment for Direct Costs

1. The social insurance agency shall make direct payments to patients according to the following provisions:

a) For medicines: The basis for calculating the level of payment is the quantity and unit price recorded on the invoice issued when the patient purchases the medicine from a business establishment. In cases where there are regulations regarding the payment ratio and conditions, such regulations shall be implemented.

b) For medical equipment (including reusable medical equipment): The basis for calculating the level of payment is the quantity and unit price recorded on the invoice issued when the patient purchases the medical equipment from a medical equipment sales establishment. In cases where there are regulations regarding the maximum level of payment for medical equipment, such regulations shall be followed.

2. The unit price of medicines and medical equipment used as the basis for determining the level of payment shall not exceed the unit price paid at the most recent time point for medicines and medical equipment that have won bids at the healthcare facility where the patient received treatment. In cases where medicines and medical equipment have not won bids at the healthcare facility where the patient received treatment, the unit price used as the basis for determining the health insurance payment level shall be the result of selecting the lowest bidder in the following order of priority:

a) Centralized procurement results or negotiation prices;

b) Local centralized procurement results within the area;

c) The lowest selection result at the time of payment among public healthcare facilities at the specialized and basic levels or healthcare facilities with the same technical expertise level within the area;

d) The lowest selection result at the time of payment among public healthcare facilities at the specialized and basic levels or healthcare facilities with the same technical expertise level within the cities of Hanoi and Ho Chi Minh City.

3. The social insurance agency shall deduct the health insurance payment costs of the healthcare facility where the patient was treated as follows:

a) In cases where the cost of medicines and medical equipment is included in the service fee for diagnosis and treatment: Deduct from the service fee for health insurance diagnosis and treatment of the healthcare facility the amount of payment according to the provisions of Clause 1 and 2 of this Article;

b) In cases where the cost of medicines and medical equipment is not included in the structure of the service fee for diagnosis and treatment: Do not deduct from the service fee for health insurance diagnosis and treatment of the healthcare facility;

c) The cost of medicines and medical equipment directly paid by the social insurance agency to the patient shall be included in the budgeted expenses of the healthcare facility.

Article 5. Documents and Procedures for Direct Payment

1. The documents for direct payment shall be carried out according to the provisions of Article 28 of Decree No. 146/2018/ND-CP dated October 17, 2018, of the Government detailing and guiding the implementation of certain provisions of the Health Insurance Law (hereinafter referred to as Decree No. 146/2018/ND-CP).

2. The procedures for direct payment shall be carried out according to the provisions of Article 29 of Decree No. 146/2018/ND-CP.

Article 6. Implementation Organization

1. The Department of Health Insurance shall be responsible for guiding and inspecting the implementation of this Circular throughout the country.

2. The Vietnam Social Security shall be responsible for directing, guiding, and inspecting the implementation of this Circular for social insurance agencies under its management authority.

3. Provincial Departments of Health and municipal departments directly under the central government shall have the following responsibilities:

a) Organize the dissemination, implementation, inspection, and supervision of the implementation of this Circular within their management authority;

b) Strengthen supervision, inspection, and supervision of purchasing to ensure the availability of medicines and medical equipment for health insurance diagnosis and treatment services at healthcare facilities under their management; implement measures to handle violations according to laws on diagnosis and treatment and health insurance against healthcare facilities that do not meet the conditions stipulated in their operating licenses and health insurance diagnosis and treatment contracts related to the supply of medicines and medical equipment;

c) Strengthen inspections and supervision of healthcare facilities under their management to ensure there is no abuse or fraud in prescribing and directing patients to purchase medicines and medical equipment themselves; strictly handle any violations according to the law.

4. The heads of healthcare facilities shall have the following responsibilities:

a) Issue regulations or guidance documents to organize the implementation of this Circular at healthcare facilities;

b) Guide practitioners to clearly note the unavailability of medicines and medical equipment in the cases specified in Clauses 1, 2, and 3 of Article 3 of this Circular on prescriptions or medical records for patients to purchase themselves;

c) Organize information, guidance, and counseling on patients' rights and health insurance benefits; provide specific information to patients about the unavailability of medicines and medical equipment and relevant provisions of this Circular so that patients can make decisions.

5. Practitioners shall strictly comply with the provisions of points b and c of Clause 4 of this Article and ensure there is no abuse or fraud in prescribing and directing patients to purchase medicines and medical equipment themselves.

6. Patients or their legally authorized representatives shall be responsible for the legality and completeness of the documents submitted for direct payment.

Article 7. Reference Provisions

In case the referenced documents in this Circular are replaced or amended, they shall be applied according to the replaced or amended documents.

Article 8. Implementation clause

1. This Circular takes effect from January 1, 2025.

2. In cases where patients enter healthcare facilities for examination and treatment before this Circular takes effect but their treatment concludes after this Circular takes effect, the provisions of this Circular shall be implemented. Any difficulties or issues arising during implementation shall be reported to the Ministry of Health for consideration and resolution.

Any difficulties or issues arising during implementation shall be reported to the Ministry of Health for consideration and resolution./.