paid directly for the cost of the drug

Direct payment for rare drugs from the Health Insurance Fund

Deputy Minister of Health Tran Van Thuan has just signed and issued Circular 22/2024/TT-BYT (Circular 22/2024) regulating the direct payment of medicine and medical equipment costs for people with health insurance cards, clearly stating the conditions, criteria and payment levels.

Accordingly, the circular stipulates the conditions and levels of benefits for the Health Insurance Fund to directly pay for the costs of drugs and medical equipment within the scope of benefits for patients with health insurance cards.

Health insurance patients are directly paid by the Health Insurance Fund for medicines and medical supplies within the scope of benefits, when health insurance medical examination and treatment facilities are in shortage.

Cases of drugs and medical equipment covered by payment include: drugs on the list of rare drugs issued with Circular No. 26/2019/TT-BYT dated August 30, 2019 of the Minister of Health regulating the list of rare drugs.

Medical equipment of type C or D, except for personal medical equipment, medical equipment in the list of medical equipment is bought and sold like normal goods.

Regarding payment conditions, Circular 22/2024 clearly states: at the time of prescribing drugs and indicating the use of medical equipment, the following conditions must be ensured: the medical facility does not have drugs or medical equipment because it is in the process of selecting a contractor according to the approved contractor selection plan.

At the same time, at the medical examination and treatment facility, there is no substitute medicine (there is no commercial medicine containing the active ingredient that the patient is prescribed or the same active ingredient but with different concentrations or content or dosage form or route of administration and cannot be substituted for the prescription for the patient).

With regard to medical equipment, health insurance patients are paid when the health insurance examination and treatment facility does not have the medical equipment that the patient is prescribed to use and does not have medical equipment to replace it.

Hospitals must ensure adequate supply of drugs and medical supplies; do not abuse prescriptions and instruct patients to buy drugs and medical equipment themselves.

Prescribed and indicated drugs and medical equipment must be in accordance with the scope of expertise of the medical examination and treatment facility and have been covered for medical examination and treatment costs covered by health insurance at one of the medical examination and treatment facilities nationwide, and prescribed and indicated drugs and medical equipment must be within the scope of benefits of the health insurance participant.

Do not profit from prescribing prescriptions for patients to buy themselves.

Circular 22/2024 also clearly states that medical examination and treatment facilities must ensure that they do not abuse or profit from prescribing and instructing patients to buy medicine and medical equipment themselves.

The patient or the patient's legal representative is responsible for the legality and completeness of the direct payment request file.

Provincial and municipal health departments shall strengthen the supervision, inspection and supervision of the procurement of medicines and medical equipment to ensure the availability of medicines and medical equipment for medical examination and treatment under health insurance at medical examination and treatment facilities under their management; handle medical examination and treatment facilities that do not meet the conditions related to the supply of medicines and medical equipment in accordance with the law.

At the same time, strengthen inspection and supervision of medical examination and treatment facilities under their management authority, ensuring that there is no abuse or profiteering in prescribing and instructing patients to self-purchase drugs and medical equipment; strictly handle violations according to the provisions of law.

The Ministry of Health also requires heads of medical examination and treatment facilities to be responsible for organizing guidance and consultation on the rights and health insurance benefits of patients; providing specific information to patients about the unavailability of drugs and medical equipment.

On the part of practitioners, the Ministry of Health requires that there be no abuse or profiteering in prescribing or instructing patients to buy medicine and medical equipment themselves.

Payment level for health insurance patients buying medicine and medical equipment themselves

According to Circular 22/2024, the Social Insurance agency makes direct payments to patients according to the following regulations:

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.

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 a valid contractor in the following order of priority: the result of centralized procurement at the national level or the result of price negotiation; the result of centralized procurement at the local level in the area.

In case the cost of medicine and medical equipment is included in the price of medical examination and treatment services: social insurance shall deduct the cost of medical examination and treatment services covered by health insurance of the medical examination and treatment facility.

Source: https://thanhnien.vn/quyen-loi-bao-hiem-y-te-moi-nhat-duoc-thanh-toan-truc-tiep-chi-phi-thuoc-185241020095620599.htm