Instructions for health insurance payment for traditional medicine

(Chinhphu.vn) - The Ministry of Health has issued Circular 27/2025/TT-BYT stipulating principles, criteria for developing, updating, recording information, structure of the list and payment instructions for herbal medicines, medicines combining active ingredients with herbal medicines, traditional medicines, and herbal medicines within the scope of benefits of health insurance participants.

Health insurance fund pays for herbal medicines, traditional medicines, medicines combining pharmaceutical ingredients with herbal medicines within the scope of benefits of health insurance participants.

This Circular stipulates the principles, criteria for developing, updating, recording information, structure of the list and payment instructions for herbal medicines, medicines combining active ingredients with herbal medicines, traditional medicines, herbal medicines (including traditional medicinal ingredients) within the scope of benefits of health insurance participants (called traditional medicine).

Payment principles

According to the Circular, the health insurance fund shall pay for the cost of herbal medicines, medicines containing pharmaceutical ingredients combined with medicinal herbs, traditional medicines, medicinal herbs, and decoctions used at medical examination and treatment facilities and medicines processed and prepared by medical examination and treatment facilities themselves based on the actual quantity used for patients, the purchase price of the facility according to the provisions of the law on bidding, the cost of loss during the process of preservation, transportation, dispensing, preparation, weighing, dividing, and using medicines according to the regulations of the Minister of Health and other costs (if any) within the scope of benefits and levels of enjoyment according to the provisions of the law on health insurance.

For management costs and depreciation costs of machinery for medicinal materials and drugs self-processed and prepared by medical examination and treatment facilities as prescribed in this Circular, the health insurance fund shall pay according to the roadmap for adjusting the components of the price of medical examination and treatment services covered by health insurance and shall be applied at the same time as the price of medical examination and treatment services covered by health insurance as prescribed.

In case the rate and payment conditions for drugs and medicinal herbs are specified in column 4 or column 5 of the notes of the Appendices issued with the Circular promulgating the list of traditional medicine drugs within the scope of benefits for health insurance participants, the health insurance fund shall pay according to the rate and payment conditions for the drugs specified in the Circular promulgating the list of traditional medicine drugs within the scope of benefits for health insurance participants.

The health insurance fund pays for herbal medicines, traditional medicines, medicines that combine active ingredients with medicinal herbs listed in the list of traditional medicines within the scope of benefits for health insurance participants or according to the name of the drug ingredients in case the drug ingredients have different names.

The health insurance fund shall pay for medicinal herbs listed in the list of medicinal herbs in the Circular promulgating the list of traditional medicine drugs within the scope of benefits for health insurance participants or according to the name of the medicinal herb in case the medicinal herb has a different name.

Payment for herbal medicines, traditional medicines, medicines combining pharmaceutical ingredients with herbal medicines

1- The health insurance fund shall pay for the cost of herbal medicines, traditional medicines, and medicines containing pharmaceutical ingredients combined with herbal medicines used for patients, including the actual cost of the medicine used for the patient and the cost of loss of the medicine (if any) at the medical examination and treatment facility, specifically as follows:

The actual cost of drugs used for a patient during a medical examination and treatment is paid by the health insurance fund based on the purchase price of the medical examination and treatment facility according to the provisions of the law on bidding and the level of benefits and scope of benefits according to the provisions of the law on health insurance.

The cost of drug loss paid by the health insurance fund during the process of storing, preserving, transporting, dispensing, preparing, dividing doses and using drugs is determined according to the provisions of Circular No. 55/2017/TT-BYT dated December 29, 2017 of the Minister of Health regulating the rate of drug loss and payment of drug loss costs at medical examination and treatment facilities.

The health insurance fund pays the loss cost for each settlement year as follows: The loss cost of drugs paid by the health insurance fund = (Drug loss rate) x (Total health insurance payment cost for that drug).

2- The health insurance fund shall pay in case the drug prescription is in accordance with the prescription of one of the following documents: Instructions for use of the drug attached to the drug registration dossier licensed by the Ministry of Health; instructions for diagnosis and treatment of diseases according to traditional medicine, combining traditional medicine with modern medicine of the Ministry of Health.

3- Medicines classified in this traditional medicine group but used to treat diseases belonging to another traditional medicine group are covered by the health insurance fund if the indication is in accordance with the provisions in Clause 2 above.

4- The health insurance fund shall pay according to the conditions and payment rates for drugs noted in column 4 or column 5 of the Appendices issued with the Circular promulgating the list of traditional medicine drugs within the scope of benefits of health insurance participants.

5- The health insurance fund does not pay in the following cases:

Drugs and batches of drugs that have been suspended from circulation or recalled by competent authorities. The time and scope of non-payment of health insurance are calculated according to the time and scope of suspension or recall stated in the suspension or recall document.

Medicine costs have been included in the price of medical examination and treatment services or the total price collected per case according to current regulations.

The cost of the drug is covered by the state budget or other funding sources.

Payment for medicinal materials

1.1- Medical examination and treatment facilities purchasing medicinal herbs for use will have the health insurance fund pay the following costs:

a) Direct costs include: Cost of medicinal materials according to the purchase price of medical examination and treatment facilities. Medicinal materials must be included in the list of medicinal materials specified in the Circular promulgating the list of health insurance drugs; costs of auxiliary materials, electricity, water, fuel used in preliminary processing (if any); costs of loss in preliminary processing, preservation, weighing and dividing (if any); packaging costs (if any); costs of materials, chemicals, and auxiliary materials for quality control activities before testing, testing costs according to Circular No. 38/2021/TT-BYT dated December 31, 2021 of the Minister of Health regulating the quality of medicinal materials, traditional medicinal herbs, and traditional medicines (if any); other costs (if any).

b) Labor costs (if any).

c) Management costs according to the roadmap for adjusting the components of the price of medical examination and treatment services under health insurance.

d) Machinery depreciation costs according to the roadmap for adjusting the components of the price of medical examination and treatment services under health insurance.

2.1- The head of the medical examination and treatment facility is responsible for approving the preliminary processing procedure, medicinal material costs and costs specified in Clause 1.1 above (if any) and sending them to the social insurance agency where the health insurance medical examination and treatment contract is signed as a basis for payment.

In addition, the Circular also specifically regulates payment for traditional medicines; payment for herbal medicines; payment for prepared medicines self-processed and prepared by medical examination and treatment facilities; and medicines paid for in special cases.

This Circular takes effect from September 1, 2025.

Minh Hien

Source: https://baochinhphu.vn/huong-dan-thanh-toan-bhyt-doi-voi-thuoc-y-hoc-co-truyen-102250702105411148.htm