Conditions for health insurance patients to be paid for their own medicine and supplies

To ensure the rights of people with health insurance cards when going to see a doctor, Deputy Minister of Health Tran Van Thuan signed Circular 22 “Regulations on direct payment of medicine and medical equipment costs for people with health insurance cards going to see a doctor”. The Circular was issued in the context of local drug shortages occurring at some medical facilities, forcing people going to see a doctor and receive treatment with health insurance to buy their own medicine.

To pay for medicine and medical equipment costs directly to health insurance patients, at the time of prescribing medicine and indicating the use of medical equipment, the following conditions must be met.

Firstly, there are no medicines or medical equipment because they are in the process of selecting contractors according to the approved contractor selection plan in one of the following forms: Open bidding, restricted bidding, or competitive bidding or direct procurement, or selecting contractors in special cases but have not yet selected a contractor, or online bidding or online procurement and have implemented a shortened bidding designation according to the provisions of the Law on Bidding and Decree No. 24 of the Government, but have not selected a contractor.

At the same time, the medical examination and treatment facility does not have any commercial drugs containing the active ingredient that the patient was prescribed, the same active ingredient but different concentration, content, dosage form, or route of administration, and cannot be substituted for the prescription for the patient. The medical examination and treatment facility does not have the medical equipment that the patient was prescribed to use, and there is no medical equipment to replace it.

Second, do not transfer patients to other medical examination and treatment facilities in one of the following cases: The patient's health condition or illness is determined to be ineligible for transfer; the medical examination and treatment facility where the patient is examined and treated is under medical isolation; the medical examination and treatment facility where the patient is examined and treated is a specialized medical examination and treatment facility.

Third, it is not possible to transfer drugs and medical equipment between medical examination and treatment facilities according to the provisions of law.

Fourth, the prescribed and indicated drugs and medical equipment must be consistent with the professional scope of the medical examination and treatment facility and have been covered by health insurance at one of the medical examination and treatment facilities nationwide.

Fifth, prescribed and indicated drugs and medical equipment must be within the scope of benefits of health insurance participants.

Health insurance patients wait to complete medical examination procedures at a medical facility in Hanoi. (Illustration photo: Nhu Loan)

In addition to stipulating a number of conditions for payment of costs, Circular 22 of the Ministry of Health also stipulates the level of direct payment for health insurance patients.

For drugs: The basis for calculating the payment level is the quantity and unit price stated on the invoice purchased by the patient at the pharmaceutical business establishment. In case the drug has regulations on payment rates and conditions, the payment rates and conditions shall be implemented.

For medical equipment (including reusable medical equipment): The basis for calculating the payment level is the quantity and unit price stated on the invoice purchased by the patient at the medical equipment trading facility. In case the medical equipment has a payment level regulation, it must not exceed the payment level prescribed for that medical equipment.

“The unit price of drugs and medical equipment used as the basis for determining the payment level must not exceed the unit price paid at the most recent time for cases where drugs and medical equipment have won bids at the medical examination and treatment facility where the patient was examined and treated,” the circular clearly states.

In case the medicine or medical equipment has not won the bid at the medical examination and treatment facility where the patient has been examined and treated, the unit price used as the basis for determining the health insurance payment level is the result of the selection of the valid contractor in order of priority.

Recently, in the context of drug and medical supplies shortage, many patients have had to buy drugs outside the hospital at prices many times higher than the prescribed health insurance price but are not reimbursed. This puts more financial burden on patients for treatment, which is unfair to those who buy health insurance.

Previously, Minister of Health Dao Hong Lan said that according to regulations, medical examination and treatment facilities must ensure enough medicine and not let patients buy medicine from outside during their inpatient treatment. If patients are allowed to buy medicine themselves, there will be many risks regarding quality and safety; the risk of over-prescription or patients having to pay high prices, making it difficult to determine payment. Therefore, the Ministry has assigned the Department of Health Insurance to develop a circular to ensure the rights of health insurance beneficiaries who have to buy medicine from outside.

Nhu Loan

Source: https://vtcnews.vn/dieu-kien-benh-nhan-bhyt-duoc-thanh-toan-chi-phi-khi-tu-mua-thuoc-vat-tu-ar902955.html