Circular 39/2024/TT-BYT amends Circular 35/2016/TT-BYT on the List and ratio, conditions for payment of medical technical services within the scope of benefit for health insurance participants issued by the Minister of Health.

 CIRCULAR

Amending and supplementing certain Articles of Circular No. 35/2016/TT-BYT dated September 28, 2016 issued by the Minister of Health on the List and Proportions, Conditions for Payment of Medical Technical Services within the Scope of Benefit for Health Insurance Participants

dated September 28, 2016

concerning medical technical services within the scope of benefit for health insurance participants

Pursuant to the Health Insurance Law No. 25/2008/QH12 dated November 14, 2008, as amended and supplemented by Law No. 46/2014/QH13 dated June 13, 2014;

                     

Pursuant to Decree No. 146/2018/NĐ-CP dated October 18, 2018 of the Government detailing and guiding implementation measures of the Health Insurance Law, as amended and supplemented by Decree No. 75/2023/NĐ-CP dated October 19, 2023;

At the proposal of the Director of the Health Insurance Department, the Director of the Planning and Finance Department, and the Director of the Medical Examination and Treatment Management Department;

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;

The Minister of Health issues this Circular amending and supplementing certain Articles of Circular No. 35/2016/TT-BYT dated September 28, 2016 of the Minister of Health on the List and Proportions, Conditions for Payment of Medical Technical Services within the Scope of Benefit for Health Insurance Participants.

Article 1. Amending and supplementing certain Articles and Clauses of Circular No. 35/2016/TT-BYT dated September 28, 2016 of the Minister of Health on the List and Proportions, Conditions for Payment of Medical Technical Services within the Scope of Benefit for Health Insurance Participants

1. Supplement Clause 7 following Clause 6 of Article 4 as follows:

"7. A single outpatient visit or hospitalization episode (outpatient treatment, day care treatment, or inpatient treatment) is determined as one visit for diagnosis and treatment. The number of days for a single visit for diagnosis and treatment shall be decided by the practitioner based on the patient's condition."

2. Amending and supplementing certain medical technical services with specific provisions regarding conditions, proportions, or payment levels set out in Circular No. 35/2016/TT-BYT dated September 28, 2016 of the Minister of Health on the List and Proportions, Conditions for Payment of Medical Technical Services within the Scope of Benefit for Health Insurance Participants (hereinafter referred to as Circular No. 35/2016/TT-BYT), including:

a) List 1. Medical technical services with specific provisions on conditions, proportions, and payment levels;

b) List 2. Medical technical services with specific provisions on payment conditions.

3. Replacing the term "hospitalization episode" with the term "single visit for diagnosis and treatment" in Circular No. 35/2016/TT-BYT, which has been amended and supplemented by Article 7 of Circular No. 50/2017/TT-BYT dated December 29, 2017 of the Minister of Health amending and supplementing relevant regulations on payment of examination and treatment costs, and Circular No. 13/2020/TT-BYT dated June 22, 2020 of the Minister of Health amending and supplementing certain Articles of Circular No. 35/2016/TT-BYT dated September 28, 2016 of the Minister of Health on the List and Proportions, Conditions for Payment of Medical Technical Services within the Scope of Benefit for Health Insurance Participants.

4. Supplementing Articles 4a, 4b, 4c, 4d following Article 4 as follows:

"Article 4a. Principles for applying service prices for healthcare facilities that have signed contracts for health insurance examination and treatment services

1. Costs not included in the bed day price, to be paid according to actual usage for patients, include:

a) Medicines, whole blood, blood products meeting standards, infusion fluids;

b) Various types of syringes, needles for injection and infusion, feeding pumps, infusion tubes, needle for puncturing infusion bags (excluding needles already included in the purchase of infusion bags according to regulations in the same set), blood transfusion tubes, stoppers at the end of infusion needles, connecting tubes, infusion pump tubes, infusion machines used in injections and infusions; oxygen, oxygen breathing tubes, oxygen masks (except cases where patients are prescribed mechanical ventilation) and other medical equipment not included in the bed day cost structure (excluding depreciation costs);

c) Artificial colostomy bags, urine collection bags, catheter bags, minicaps (only applicable for cases requiring replacement after surgery or procedures, not reimbursed concurrently with surgical or procedural costs already included in the cost structure);

d) External sprays used for pressure sore prevention. Reimbursement is provided for patients diagnosed with stage 1 pressure sores, with a maximum of three bottles (20 ml/bottle) per treatment episode.

2. Costs not included in the technical service price, to be paid according to actual usage for patients, are noted in the pricing documents or approved prices.

3. Healthcare facilities shall not charge patients for medicines, consumables, and replacement items within the scope of health insurance fund reimbursement already included in the prices of services covered by the social insurance agency, except for some special cases specifically noted."

3. Medical examination and treatment facilities shall not charge patients for medication costs, consumable supplies, and replacement materials within the scope of payment by the Health Insurance Fund that are included in the prices of services paid by the social insurance agency, except for certain specific cases which have been specifically noted.

Article 4b. Determining the number of times, price level, and payment for outpatient medical examination in certain specific cases

1. In cases where patients come to the outpatient department for medical examination and are then referred for inpatient treatment according to professional requirements, the payment for outpatient medical examination shall be implemented in accordance with the provisions of Clause 3 of this Article. In cases where patients do not register for outpatient medical examination at the outpatient department but come for medical examination and inpatient treatment at clinical departments according to professional requirements, there will be no payment for outpatient medical examination.

2. Medical examination and treatment facilities that organize specialized medical examinations at clinical departments, where patients register for medical examination at the outpatient department and undergo specialized medical examinations at clinical departments, shall be considered as undergoing medical examination at the outpatient department. The calculation of the number of medical examinations and price levels shall be carried out in accordance with the provisions of Clause 3 of this Article.

3. Within the same visit to the same medical examination and treatment facility (which may be on the same day or due to objective conditions or professional requirements, the medical examination process cannot be completed on the same day and must continue on the following day), if a patient needs to undergo additional specialized medical examinations after the first specialized medical examination, from the second examination onwards, only 30% of the price of one medical examination will be charged, and the maximum payment for medical examination costs for that person shall not exceed twice the price of one medical examination.

Example 1: Patient A undergoes internal medicine specialized medical examination, and is then referred for surgical specialized medical examination by the doctor, the price of the surgical specialized medical examination (second examination) will be calculated as 30% of the price of the first examination (internal medicine).

Example 2: Patient A undergoes neurology internal medicine specialized medical examination, and is then referred for neurosurgery specialized medical examination by the doctor, the price of the neurosurgery specialized medical examination (second examination) will be calculated as 30% of the price of the first examination (neurology internal medicine).

Example 3: Patient A undergoes cardiology internal medicine specialized medical examination, and is then referred for gastroenterology internal medicine specialized medical examination by the doctor, the price of the gastroenterology internal medicine specialized medical examination (second examination) will be calculated as 30% of the price of the first examination (cardiology internal medicine).

Example 4: Patient A undergoes otolaryngology specialized medical examination, and is then referred for advanced audiological examination (vestibular/inner ear), the price of the advanced audiological examination (second examination) will be calculated as 30% of the price of the first examination (otolaryngology).

4. Patients who come to medical examination and treatment facilities, have undergone medical examination and been prescribed medication for outpatient treatment, but later show abnormal symptoms and return to the same medical examination and treatment facility on the same day for re-examination and further examination, such re-examination will be considered as the second examination or subsequent examinations within the same day, except in emergency cases which are counted as a new examination. Payment shall be made in accordance with the provisions of Clause 3 of this Article.

5. Medical examination and treatment facilities must coordinate and arrange human resources and the number of examination tables to ensure the quality of medical examination. For examination tables with more than 65 examination sessions within an 8-hour period in one day, the social insurance agency will only pay 50% of the medical examination fee from the 66th session onwards of that examination table. If within a consecutive period of up to three months, the medical examination and treatment facility still has examination tables with more than 65 sessions per day, the social insurance agency will not pay for medical examination fees from the 66th session onwards of those examination tables.

Example: If the medical examination schedule is extended to 10 hours (by working two extra hours), the number of examination sessions per examination table for 10 hours of work is 65:8x10 = 81 sessions.

Article 4c. Determining the number of bed days, applying rates, and settling bed day fees between social insurance agencies and healthcare facilities

1. Determining the number of inpatient treatment bed days for payment of hospitalization fees:

a) The number of inpatient treatment days equals the discharge date minus (-) the admission date plus (+) 1: applicable to cases where:

- The patient undergoing inpatient treatment dies or their condition worsens and the family requests to be discharged or transferred to another healthcare facility;

- The patient has been treated through the emergency phase but still requires continued inpatient treatment and is transferred to another healthcare facility;

b) The number of inpatient treatment days equals the discharge date minus (-) the admission date: applicable to all other cases;

c) In cases where the patient is admitted and discharged on the same day (or admitted the previous day and discharged the following day), with a treatment time exceeding 04 hours but less than 24 hours, it shall be counted as one day of inpatient treatment. For patients admitted to the emergency department without first visiting the outpatient department, if the emergency treatment and care time is 04 hours or less (including cases of discharge, admission, transfer, or death), only outpatient examination fees, medication costs, medical equipment, and technical service fees will be settled, not hospitalization bed fees;

d) In cases where the patient's treatment time is 04 hours or less, only outpatient examination fees, medication costs, medical equipment, and technical service fees used by the patient will be settled, not inpatient hospitalization bed fees;

2. If a patient transfers between two departments on the same day, each department shall only count half a day. If a patient transfers among three or more departments on the same day, the bed service fee for that day shall be calculated based on the average of the highest and lowest bed day prices at departments where the patient stayed for over 04 hours;

3. Postoperative bed service fees for surgical and burn wards: apply a maximum of 10 days post-surgery, including cases where the patient is treated at one healthcare facility or transferred to other healthcare facilities. From the 11th day post-surgery onwards, the inpatient ward bed service fee rate of the corresponding department shall be applied;

During the 10 days post-surgery, if the patient is transferred to another healthcare facility, the receiving healthcare facility shall apply the surgical bed service fee rate according to the surgery performed on the patient. The number of days the receiving healthcare facility can settle is 10 days minus the number of days the patient was treated at the transferring healthcare facility. The transferring healthcare facility must record the surgery date on the referral form;

If a patient needs to continue postoperative treatment while also requiring inpatient treatment in another clinical department, they may apply the maximum surgical bed service fee rate for up to 10 days post-surgery;

Example: Patient A, after kidney surgery, is referred by a doctor to continue kidney treatment in the nephrology (internal medicine) department, and thus applies the maximum surgical bed service fee rate for up to 10 days post-surgery. From the 11th day onwards, the current bed service fee rate of the nephrology department shall be applied;

4. The bed service fee is calculated as follows:

a) One person per bed;

b) If two people share one bed at the same time, only half the bed service fee rate shall be settled. If three or more people share one bed, only one-third of the bed service fee rate shall be settled;

c) If a hospital adjusts its bed capacity according to Clause 3, Article 67 of Decree No. 96/2023/NĐ-CP, additional beds shall be settled at the approved price by the competent authority;

5. Intensive Care Unit (ICU) bed service fees shall be applied in the following cases:

a) Healthcare facilities with ICU beds in specialized departments such as Intensive Care, Poison Control, Intensive Care - Poison Control, Emergency - Intensive Care - Poison Control, which meet the conditions for operation as stipulated in Decision No. 01/2008/QĐ-BYT dated January 21, 2008, issued by the Minister of Health regarding the issuance of emergency, intensive care, and poison control regulations (hereinafter referred to as Decision No. 01/2008/QĐ-BYT) and Circular No. 03/2023/TT-BYT dated February 17, 2023, issued by the Minister of Health guiding job positions, staffing levels, and personnel structures in public health institutions (hereinafter referred to as Circular No. 03/2023/TT-BYT);

b) Specialized departments of healthcare facilities that have ICU beds or postoperative beds for special surgeries that meet the requirements for infrastructure, equipment, and human resources as stipulated in the Emergency, Intensive Care, and Poison Control Regulations issued together with Decision No. 01/2008/QĐ-BYT and Circular No. 03/2023/TT-BYT;

c) Patients staying in beds specified in points a and b of this clause with diseases requiring care, treatment, and monitoring under emergency, intensive care, and poison control regulations. Other cases shall only apply the bed service fee rate for emergency ICU beds and other types of beds as prescribed by the competent authority;

6. For clinical departments with emergency ICU beds: apply the emergency ICU bed service fee rate as prescribed by the competent authority;

Example: the pediatric department with pediatric emergency ICU beds, neonatal or special care departments for premature infants;

7. In cases where a single surgery is classified differently across specialties (excluding pediatrics): apply the surgical and burn ward bed service fee rate based on the lowest surgery classification.

8. For surgeries not classified under surgery types: apply the level 4 ward bed service price of the corresponding hospital.

9. For traditional medicine hospitals directly under the Ministry of Health, the Ministry of National Defense, and the Ministry of Public Security: apply the ward bed service price according to the respective departments approved by the competent authority.

10. For departments within rehabilitation hospitals and traditional medicine hospitals except those specified in Clause 9 of this Article:

a) Intensive Care Unit (ICU) ward bed service price: as stipulated in Clause 5 of this Article;

b) Emergency Intensive Care ward bed service price: as stipulated in Clause 6 of this Article;

c) Ward bed service price for departments specializing in oncology and pediatrics: apply the level 1 internal ward bed service price;

d) Ward bed service price for treating spinal cord injury, stroke, and brain trauma: apply the level 2 internal ward bed service price;

đ) Ward bed service price for other departments: apply the level 3 internal ward bed service price;

11. For ward beds in departments without specified prices: apply the lowest internal ward bed price approved by the competent authority of that facility.

12. For healthcare facilities organizing interdisciplinary departments: apply the internal ward bed service price corresponding to the patient's treatment department. In cases where a patient is treated for multiple diseases simultaneously, apply the ward bed service price of the primary treatment department.

13. In cases where patients lie on stretchers or folding beds: apply 50% of the ward bed service price according to each specialty type.

14. In cases where patients have been scheduled for surgery but are not yet eligible due to pre-surgery treatment requirements: during the treatment period, apply the internal ward bed service price corresponding to the patient's treatment.

Example: A patient with a bone fracture lies in the surgical department, scheduled for bone setting surgery, and suffers from blood coagulation disorder requiring treatment to meet surgery eligibility criteria. During the treatment period in the surgical department, apply the internal ward bed service price of the hematology specialty.

15. Postoperative ward bed service price for "Phaco Cataract Surgery": apply the level 3 burn ward bed service price approved by the competent authority.

Article 4d. Application of Prices and Conditions for Payment of Certain Special Technical Services

1. For technical services already approved by the competent authority in the technical service catalog (excluding care services included in the daily ward bed cost, and services that are part of another procedure's cost), but without specified prices; for technical services that were ordered but could not be performed due to disease progression or patient condition, healthcare facilities shall be reimbursed according to point b, Clause 3, Article 24 of Decree No. 146/2018/NĐ-CP dated November 19, 2018, detailing and guiding the implementation of certain provisions of the Health Insurance Law, amended and supplemented by Decree No. 75/2023/NĐ-CP.

2. In cases of multiple interventions during a single surgery: reimbursement shall be based on the most complex surgery with the highest price, and other technical services arising outside the surgical procedure will be reimbursed as follows:

a) At 50% of the price of additional surgeries if the same surgical team performs them;

b) At 80% of the price of additional surgeries if a different surgical team is required;

c) If the additional service is a procedure, it will be reimbursed at 80% of the price of the additional technical service.

3. For the service "Changing Dressing on Wounds or Incisions up to 15 cm in Length":

a) Reimbursement for inpatient patients in the following cases: infected wounds or incisions; wounds with fluid or blood leakage in skin avulsion injuries or open skin areas larger than 6 cm²; wounds with gauze packing; foot wounds with excessive drainage; multiple wounds or incisions; or after surgery requiring two or more incisions;

b) Not applicable for changing dressings in the following cases: laparoscopic surgery, routine wound dressing changes, or umbilical cord dressing changes for newborns.

4. For the service "Changing Dressing on Incisions over 15 cm to 30 cm in Length" for inpatients, only apply in the following cases:

a) Infected incisions, gastrointestinal fistulas, bile fistulas, urinary fistulas;

b) Incisions after contaminated surgery (peritonitis or osteomyelitis or abscess), incisions after digestive tract, urinary system, bile duct, or abdominal ascites surgery;

c) Incisions after surgery requiring two or more incisions;
d) In cases of cesarean section surgery: apply this price but not more than three times.

5. For immunological crossmatching tests at 37°C using anti-globulin serum (indirect Coombs test) in blood transfusions: Reimburse according to the price of the "Crossmatching Service Using Anti-Globulin Human Serum" approved for the facility;

6. Quarterly settlement of certain technical services such as: conventional X-ray, digital X-ray, CT Scanner up to 32 slices, ultrasound, MRI: The health insurance agency and healthcare facilities shall implement as follows:

a) Determine the maximum number of cases reimbursable by the social insurance agency at the approved price by dividing the average number of cases calculated by the pricing standard by 8, then multiplying the result by the actual working hours of the unit, then multiplying by the actual number of working days in the quarter, then multiplying by the actual number of machines operating in the quarter, and finally multiplying by 120%.

b) Rate standard (number of cases/machine/eight-hour working day): ultrasound service is 48 cases; conventional X-ray, digital X-ray is 58 cases; CT Scanner up to 32 rows is 29 cases; Magnetic Resonance Imaging (MRI) is 19 cases;

c) In the case where the number of cases proposed for payment is less than or equal to the maximum number of cases according to the calculation method prescribed in point a of this clause: the social insurance agency shall pay according to the actual number of cases and the price level approved for the facility;

d) In the case where the number of cases proposed for payment exceeds the maximum number of cases according to the calculation method prescribed in point a of this clause: For the number of cases equal to the maximum number of cases according to the calculation method at point a of this clause, the social insurance agency shall pay according to the price level approved for the facility. For the number of cases exceeding the maximum number of cases according to the calculation method at point a of this clause, the social insurance agency shall pay according to the price excluding labor costs, with specific payment prices as follows:

- Ultrasound service (diagnosis): 55% of the prescribed price;

- Conventional X-ray; Digital X-ray: 85% of the prescribed price;

- CT Scanner up to 32 rows service: 95% of the prescribed price;

- Magnetic Resonance Imaging (MRI) service: 97% of the prescribed price.

Example: Facility A has 3 X-ray machines in operation, with actual working hours of 9 hours (working 1 extra hour/day); the facility organized outpatient services on Saturdays in the third quarter of 2018 for 92 days, with 78 working days in the quarter;

The maximum number of cases that the health insurance agency will pay according to the X-ray price specified in this Circular is: (58:8) X 9 X 3 X 78 X 120% = 18,322.2 cases.

If the total number of X-ray cases proposed for payment by the facility in the third quarter of 2018 is less than or equal to 18,322 cases, it will be paid according to the price specified in this Circular.

In the case where the number of cases proposed for payment by the facility exceeds 18,322 cases, for example 20,000 cases, the social insurance agency will pay 18,322 cases according to the price specified in this Circular, and the remaining 1,678 cases (=20,000 cases - 18,322 cases) will be paid at 85% of the price specified in this Circular.

7. The provisions of Clause 6 of this Article and Clause 5 of Article 4b of this Circular only apply to payments between the social insurance agency and healthcare facilities and do not apply to calculating co-payment costs for patients.

8. During the period when natural disasters, accidents, epidemics occur as provided for in laws on disaster prevention and control; civil defense; infectious disease prevention and control, announced by competent authorities: the social insurance agency will pay healthcare facilities based on the actual service prices and quantities, without applying the payment regulations stipulated in Clause 6 of this Article and Clause 5 of Article 4b of this Circular.

9. A technique currently classified under different specialties or departments with different pricing levels may be performed across multiple specialties or departments and applied according to the technical service pricing of each specialty or department.

10. Technical services listed only in the pediatric specialty but performed for patients over 16 years old: apply the technical service pricing as specified in the pediatric specialty.

11. Anesthesia costs:

The price of surgeries already includes anesthesia or local anesthesia costs (except for the Ophthalmology specialty). When performing ophthalmic surgery with anesthesia, the anesthesia cost will be paid separately according to the price of the anesthesia service during eye surgery approved by the competent authority for the healthcare facility.

The price of procedures already includes pre-anesthesia sedation drug costs, but does not include anesthesia costs (except where specifically noted to include anesthesia costs in each service).

When performing a procedure requiring anesthesia, the anesthesia cost for ophthalmic procedures will be paid separately according to the price of the anesthesia service during eye procedures approved by the competent authority for the healthcare facility; other anesthesia costs for the remaining procedures will be paid according to the price of other anesthesia services approved by the competent authority for the healthcare facility.

12. Blood group typing service using tube method, slide method, or paper card method in blood transfusion is paid as follows:

a) Blood group typing in the laboratory when issuing whole blood and blood components:

- Blood group typing for patients: paid once according to the approved price (as the service price already includes the cost of two blood group typing tests using the tube method or slide method on the same sample or two samples from the same patient);

- Blood group typing of blood units or blood component units: paid once according to the service price "Blood group typing using paper card for whole blood transfusion or red cell components";

- In the case where a patient receives multiple blood units or blood component units at the same time, starting from the second unit onwards, each additional unit will be paid once for blood group typing of the blood unit according to the service price "Blood group typing using paper card for whole blood transfusion or red cell components". In this case, there is no need to determine the patient's blood group again as it was determined when the first unit was issued.

b) Blood group typing at the bedside:

- Blood group typing at the bedside when the patient receives whole blood or red cell components: paid once according to the service price "Blood group typing using paper card for whole blood transfusion or red cell components";

- Blood group typing at the bedside when the patient receives plasma components or platelet components: paid once according to the service price "Blood group typing using paper card for plasma components or platelet components".

In cases where a patient receives multiple units of blood or blood products at the same time, starting from the second unit of blood or blood product, an additional charge for one bed-side ABO blood group determination service at the rate of the "ABO blood group determination using blood grouping paper for whole blood transfusion: red cell mass, white cell mass" service shall be applied; the number of ABO blood group determinations at the bedside shall be carried out in accordance with the regulations of the Ministry of Health.

- The price level of the ABO blood group determination services "ABO blood group determination using blood grouping paper for whole blood transfusion, red cell mass, white cell mass; ABO blood group determination using blood grouping paper for platelet or plasma transfusion; ABO blood group determination using test tube method; on slide or on paper" is uniformly defined for all methods such as test tube, slide, or paper.

Article 2. Effective Date

1. This Circular shall take effect from January 1, 2025.

2. Repeal Item 14 of List 1 and Items 12, 37, 50 of List 2 issued together with Circular No. 35/2016/TT-BYT.

3. Amend and repeal certain provisions of Article 5 of Circular No. 21/2024/TT-BYT dated October 17, 2024 of the Ministry of Health regarding the pricing method for medical examination and treatment services as follows:

a) Amend the phrase "Adjust information before comparison" in Clause 3 to read "Based on Clause 1 of this Article, use the collected information price as the comparison price".

b) Repeal the phrase "after adjustment" in Clause 4.

4. Payment for medical examination and treatment costs under health insurance for cases that have undergone medical examination and treatment prior to the effective date of this Circular and for patients admitted to hospital before the effective date of this Circular but discharged after the effective date of this Circular shall be governed by the provisions of laws and legal documents promulgated before the effective date of this Circular.

5. As of January 1, 2025, contracts for medical examination and treatment under health insurance must specify the number of hospital beds of the medical examination and treatment facility as the basis for determining payment for medical examination and treatment costs under health insurance. The medical examination and treatment facility is responsible for notifying the social insurance agency where the contract was signed to adjust the contract or supplement the contract appendix when adjusting the scale of hospital beds.

6. In cases where the referenced documents in this Circular are replaced or amended, they shall be implemented according to the replaced or amended documents.

Article 3. Responsibility for Implementation

1. The Director of the Health Insurance Department, the Head of the Ministry's Office, the Inspector General of the Ministry, the Heads of Departments and Bureaus under the Ministry of Health, the Directors of Health Services of provinces and centrally-administered cities, the Heads of health agencies under ministries and sectors, and related agencies and units are responsible for implementing this Circular.

2. The Vietnam Social Security shall organize the implementation and payment of medical examination and treatment costs under health insurance in accordance with the laws on health insurance and this Circular. During the implementation process, if there are difficulties or obstacles, it is requested that agencies, organizations, and individuals report them in writing to the Ministry of Health for consideration and resolution.

During the implementation process, if there are difficulties or obstacles, it is requested that agencies, organizations, and individuals report them in writing to the Ministry of Health for consideration and resolution./.